Asymptomatic Females Are at Higher Risk for Perioperative TIA/Stroke and Males Are at Higher Risk for Long-Term Mortality after Carotid Artery Stenting: A Vascular Quality Initiative Analysis

Abstract

The study aims to review the sex differences with respect to transient ischemic attack (TIA)/stroke and death in the perioperative period and on long-term follow-up among asymptomatic patients treated with carotid stenting (CAS) in the vascular quality initiative (VQI). All cases reported to VQI of asymptomatic CAS (ACAS) patients were reviewed. The primary end point was risk of TIA/stroke and death in the in-hospital perioperative period and in the long-term follow-up. The secondary end point was to evaluate predictors of in-hospital perioperative TIA/stroke and mortality on long-term follow-up after CAS. There were 22,079 CAS procedures captured from January 2005 to April 2019. There were 5,785 (62.7%) patients in the ACAS group. The rate of in-hospital TIA/stroke was higher in female patients (2.7 vs. 1.87%, p = 0.005) and the rate of death was not significant (0.03 vs. 0.07%, p = 0.66). On multivariable logistic regression analysis, prior/current smoking history (odds ratio = 0.58 [95% confidence interval or CI = 0.39–0.87]; p = 0.008) is a predictor of in-hospital TIA/stroke in females. The long-term all-cause mortality is significantly higher in male patients (26.9 vs. 15.7%, p < 0.001). On multivariable Cox-regression analysis, prior/current smoking history (hazard ratio or HR = 1.17 [95% CI = 1.01–1.34]; p = 0.03), coronary artery disease or CAD (HR = 1.15 [95% CI = 1.03–1.28]; p = 0.009), chronic obstructive pulmonary disease or COPD (HR = 1.73 [95% CI = 1.55–1.93]; p < 0.001), threat to life American Society of Anesthesiologists (ASA) class (HR = 2.3 [95% CI = 1.43–3.70]; p = 0.0006), moribund ASA class (HR = 5.66 [95% CI = 2.24–14.29]; p = 0.0003), and low hemoglobin levels (HR = 0.84 [95% CI = 0.82–0.86]; p < 0.001) are the predictors of long-term mortality. In asymptomatic carotid disease patients, women had higher rates of in-hospital perioperative TIA/stroke and a predictor of TIA/stroke is a prior/current history of smoking. Meanwhile, long-term all-cause mortality is higher for male patients compared with their female counterparts. Predictors of long-term mortality are prior/current smoking history, CAD, COPD, higher ASA classification of physical status, and low hemoglobin level. These data should be considered prior to offering CAS to asymptomatic female and male patients and careful risks versus benefits discussion should be offered to each individual patient.

Keywords

carotid endarterectomy - carotid stenosis - carotid stent - internal carotid artery - artery - atherosclerosis

• References

• 1 Barnett HJ, Taylor DW, Eliasziw M. et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339 (20) 1415-1425
• 2 Hobson II RW, Brott T, Ferguson R. et al. CREST: carotid revascularization endarterectomy versus stent trial. Cardiovasc Surg 1997; 5 (05) 457-458
• 3 Barnett HJ. Surgery was beneficial for severe carotid stenosis in patients with symptomatic carotid ischemia. Evid Based Cardiovasc Med 1998; 2 (03) 78
• 4 Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273 (18) 1421-1428
• 5 Brott TG, Hobson II RW, Howard G. et al; CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363 (01) 11-23
• 6 Goodney PP, Lucas FL, Travis LL, Likosky DS, Malenka DJ, Fisher ES. Changes in the use of carotid revascularization among the medicare population. Arch Surg 2008; 143 (02) 170-173
• 7 Roger VL, Go AS, Lloyd-Jones DM. et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation 2012; 125 (01) e2-e220
• 8 Werner N, Zeymer U, Mark B. et al; Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK). Carotid artery stenting in clinical practice: does sex matter? Results from the carotid artery stenting registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK). Clin Cardiol 2012; 35 (02) 111-118
• 9 Goldstein LJ, Khan HU, Sambol EB, Kent KC, Faries PL, Vouyouka AG. Carotid artery stenting is safe and associated with comparable outcomes in men and women. J Vasc Surg 2009; 49 (02) 315-323 , discussion 323–324
• 10 Casana R, Malloggi C, Tolva VS. et al. Three-year outcomes after carotid artery revascularization: gender-related differences. Vascular 2019; 27 (05) 459-467
• 11 Howard VJ, Lutsep HL, Mackey A. et al; CREST investigators. Influence of sex on outcomes of stenting versus endarterectomy: a subgroup analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Lancet Neurol 2011; 10 (06) 530-537
• 12 Bennett KM, Hoch JR, Scarborough JE. Predictors of 30-day postoperative major adverse clinical events after carotid artery stenting: an analysis of the procedure-targeted American College of Surgeons National Surgical Quality Improvement Program. J Vasc Surg 2017; 66 (04) 1093-1099
• 13 Erben Y, Li Y, Da Rocha-Franco JA, Tawk RG, Barrett KM, Freeman WD, Lin M, Miller D, Beck AW, Scali ST, Farres H, Brott TG, Meschia JF, Hakaim AG. Higher Long-Term Mortality with Carotid Artery Stenting in Asymptomatic Male Compared with Female Patients in the Southeastern Vascular Study Group. Ann Vasc Surg 2020; Jul; 66: 390-399
• 14 Cronenwett JL, Likosky DS, Russell MT, Eldrup-Jorgensen J, Stanley AC, Nolan BW. ; VSGNNE. A regional registry for quality assurance and improvement: the Vascular Study Group of Northern New England (VSGNNE). J Vasc Surg 2007; 46 (06) 1093-1101 , discussion 1101–1102
• 15 Sheikh K, Bullock C. Sex differences in carotid endarterectomy utilization and 30-day postoperative mortality. Neurology 2003; 60 (03) 471-476
• 16 Lee JW, Pomposelli F, Park KW. Association of sex with perioperative mortality and morbidity after carotid endarterectomy for asymptomatic carotid stenosis. J Cardiothorac Vasc Anesth 2003; 17 (01) 10-16
• 17 Bond R, Rerkasem K, Cuffe R, Rothwell PM. A systematic review of the associations between age and sex and the operative risks of carotid endarterectomy. Cerebrovasc Dis 2005; 20 (02) 69-77
• 18 Hegele RA, Eliasziw M, De Angelis M. Sex, diabetes, and stroke after carotid endarterectomy. Diabetes Care 2003; 26 (05) 1641
• 19 Schmid S, Tsantilas P, Knappich C. et al. Risk of inhospital stroke or death is associated with age but not sex in patients treated with carotid endarterectomy for asymptomatic or symptomatic stenosis in routine practice: secondary data analysis of the Nationwide German Statutory Quality Assurance Database From 2009 to 2014. J Am Heart Assoc 2017; 6 (03) e004764
• 20 Kuy S, Dua A, Desai SS. et al. Carotid endarterectomy national trends over a decade: does sex matter?. Ann Vasc Surg 2014; 28 (04) 887-892
• 21 Howard VJ, Voeks JH, Lutsep HL. et al. Does sex matter? Thirty-day stroke and death rates after carotid artery stenting in women versus men: results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) lead-in phase. Stroke 2009; 40 (04) 1140-1147
• 22 Luebke T, Brunkwall J. Meta-analysis and meta-regression analysis of the associations between sex and the operative outcomes of carotid endarterectomy. BMC Cardiovasc Disord 2015; 15: 32
• 23 Guzman RP, Weighell W, Guzman C, Rodriguez-Leyva D. Female sex does not influence 30-day stroke and mortality rates after carotid endarterectomy. Ann Vasc Surg 2014; 28 (01) 245-252
• 24 Brown MM, Raine R. Should sex influence the choice between carotid stenting and carotid endarterectomy?. Lancet Neurol 2011; 10 (06) 494-497
• 25 Kapral MK, Wang H, Austin PC. et al; Ontario Carotid Endarterectomy Registry. Sex differences in carotid endarterectomy outcomes: results from the Ontario Carotid Endarterectomy Registry. Stroke 2003; 34 (05) 1120-1125
• 26 Chang JB, Stein TA. Sex differences in carotid endarterectomy outcomes. Stroke 2003; 34 (10) e187 , author reply e187
• 27 Ballotta E. Female sex: a questionable risk factor for carotid endarterectomy. Stroke 2003; 34 (05) 1120-1125
• 28 Hicks CW, Talbott K, Canner JK. et al. Risk of disease progression in patients with moderate asymptomatic carotid artery stenosis: implications of tobacco use and dual antiplatelet therapy. Ann Vasc Surg 2015; 29 (01) 1-8
• 29 Pan B, Jin X, Jun L, Qiu S, Zheng Q, Pan M. The relationship between smoking and stroke: a meta-analysis. Medicine (Baltimore) 2019; 98 (12) e14872
• 30 Dua A, Romanelli M, Upchurch Jr GR. et al. Predictors of poor outcome after carotid intervention. J Vasc Surg 2016; 64 (03) 663-670
• 31 Hooper GJ, Rothwell AG, Hooper NM, Frampton C. The relationship between the American Society of Anesthesiologists physical rating and outcome following total hip and knee arthroplasty: an analysis of the New Zealand Joint Registry. J Bone Joint Surg Am 2012; 94 (12) 1065-1070
• 32 Lomazzi C, Mariscalco G, Piffaretti G. et al. Endovascular treatment of elective abdominal aortic aneurysms: independent predictors of early and late mortality. Ann Vasc Surg 2011; 25 (03) 299-305
• 33 Numasawa Y, Ueda I, Sawano M. et al. Relation of baseline hemoglobin level to in-hospital outcomes in patients who undergo percutaneous coronary intervention (from a Japanese Multicenter Registry). Am J Cardiol 2018; 121 (06) 695-702
• 34 Dündar C, Oduncu V, Erkol A. et al. In-hospital prognostic value of hemoglobin levels on admission in patients with acute ST segment elevation myocardial infarction undergoing primary angioplasty. Clin Res Cardiol 2012; 101 (01) 37-44
• 35 De Santo L, Romano G, Della Corte A. et al. Preoperative anemia in patients undergoing coronary artery bypass grafting predicts acute kidney injury. J Thorac Cardiovasc Surg 2009; 138 (04) 965-970
• 36 Oshin OA, Torella F. Low hemoglobin concentration is associated with poor outcome after peripheral arterial surgery. Vasc Endovascular Surg 2013; 47 (06) 449-453
• 37 van Straten AH, Hamad MA, van Zundert AJ, Martens EJ, Schönberger JP, de Wolf AM. Preoperative hemoglobin level as a predictor of survival after coronary artery bypass grafting: a comparison with the matched general population. Circulation 2009; 120 (02) 118-125
• 38 Abbott AL, Paraskevas KI, Kakkos SK. et al. systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis. Stroke 2015; 46 (11) 3288-3301