In-hospital outcomes after carotid endarterectomy for stroke stratified by modified Rankin scale score and time of intervention

Association Between Asian Race and Perioperative Outcomes After Carotid Revascularization Varies with Asian Procedure Density

OBJECTIVE

Postoperative outcomes following carotid revascularization are understudied in Asian patients. We aimed to assess whether disease severity and postoperative outcomes following carotid revascularization differ between Asian and White patients, and whether this varies with Asian procedure density.

METHODS

We analyzed the Vascular Quality Initiative Carotid Endarterectomy and Carotid Artery Stenting datasets from 2003-2021. Regions were divided into tertiles based on Asian procedure density. Propensity scores were used to match Asian and White patients based on patient factors and procedure type. The primary outcome variable was a collapsed composite of in-hospital ipsilateral stroke/death/myocardial infarction. Chi-square tests were used to assess association between Asian race and disease severity, center and surgeon volume, and 1-year outcomes. Logistic and Cox regressions were performed between the matched cohorts.

RESULTS

A total of 1,766 Asian and 159,608 White patients underwent carotid revascularization and we identified 2,704 patients (1,352 Asian and 1,352 White) in the matched cohorts. Among propensity matched patients, all-comer Asian patients more commonly had >80% ipsilateral stenosis (63% vs. 52%, P<.001) and a moderate/severe preoperative Rankin score (7.6% vs. 5.1%, P=.007). The rate of in-hospital stroke/death/myocardial infarction was higher in Asian patients (2.6% vs. 1.3%, P=.012), and this disparity was more pronounced in the lowest tertile of Asian procedure density (4.3% vs. 0.5%, P<.001). Logistic regression in the propensity matched cohort demonstrated Asian race was associated with lower odds of intervention at highest volume centers (OR, 0.3; CI, 0.2-0.3; P<.001) and by highest volume surgeons (OR, 0.3; CI, 0.3-0.4; P<.001). Asian race was associated with higher odds of in-hospital stroke/death/myocardial infarction (OR, 2.0; CI, 1.1-3.8; P=.031), and there was a significant interaction between Asian procedure density and the relationship between Asian race and this outcome (interaction P=.001). After accounting for center and surgeon volume, the association of Asian race and the composite outcome was mitigated (OR, 1.5; CI, 0.7-3.3; P=.300). Cox regression between the matched cohorts demonstrated that Asian race was associated with lower 1-year mortality (HR, 0.5; CI, 0.3-0.7; P=.001) and higher risk of 1-year reintervention (HR, 16; CI, 1.8-142; P=.013).

CONCLUSION

Asian patients are more likely to present with a higher degree of carotid stenosis, higher preoperative risk, and experience worse perioperative outcomes. The association of Asian race with perioperative stroke/death/myocardial infarction varies with Asian procedure density and is also confounded by center and surgeon volume. These results highlight the importance of understanding referral patterns and cultural effects on outcomes disparities in Asian patients.

Outcomes following carotid revascularization for stroke stratified by Modified Rankin Scale and time of intervention

OBJECTIVES

The relationship between baseline Modified Rankin Scale (mRS) in patients with prior stroke and optimal timing of carotid revascularization is unclear. Therefore, we evaluated the timing of transfemoral carotid artery stenting (tfCAS), transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) after prior stroke, stratified by preoperative mRS.

METHODS

We identified patients with recent stroke who underwent tfCAS, TCAR, or CEA between 2012 and 2021. Patients were stratified by preoperative mRS (0-1, 2, 3-4, or 5) and days from symptom onset to intervention (time to intervention; ≤2 days, 3-14 days, 15-90 days, and 91-180 days). First, we performed univariate analyses comparing in-hospital outcomes between separate mRS or time-to-intervention cohorts for all carotid intervention methods. Afterward, multivariable logistic regression was used to adjust for demographics and comorbidities across groups, and outcomes between the various intervention methods were compared. Primary outcome was the in-hospital stroke/death rate.

RESULTS

We identified 4260 patients who underwent tfCAS, 3130 patients who underwent TCAR, and 20,012 patients who underwent CEA. Patients were most likely to have minimal disability (mRS, 0-1 [61%]) and least likely to have severe disability (mRS, 5 [1.5%]). Patients most often underwent revascularization in 3 to 14 days (45%). Across all intervention methods, increasing preoperative mRS was associated with higher procedural in-hospital stroke/death (all P < .03), whereas increasing time to intervention was associated with lower stroke/death rates (all P < .01). After adjustment for demographics and comorbidities, undergoing tfCAS was associated with higher stroke/death compared with undergoing CEA (adjusted odds ratio, 1.6; 95% confidence interval, 1.3-1.9; P < .01) or undergoing TCAR (adjusted odds ratio, 1.3; 95% confidence interval, 1.0-1.8; P = .03).

CONCLUSIONS

In patients with preoperative stroke, optimal timing for carotid revascularization varies with stroke severity. Increasing preoperative mRS was associated with higher procedural in-hospital stroke/death rates, whereas increasing time to-intervention was associated with lower stroke/death rates. Overall, patients undergoing CEA were associated with lower in-hospital stroke/deaths. To determine benefit for delayed intervention, these results should be weighed against the risk of recurrent stroke during the interval before intervention.