RS04 - Outcomes of Carotid Revascularization stratified by Procedure in eGFR<30 and Hemodialysis Patients

Wednesday, June 19, 2024

10:12 AM – 10:19 AM CT

Location: West Building, Level 3, Skyline Ballroom W375ab

Submitting & Presenting Author(s)

Elisa Caron, MD (she/her/hers)

Research Fellow in Vascular Surgery
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
Waltham, Massachusetts

Co-Author(s)

SY

Sai Divya Yadavalli, MD (she/her/hers)

Postdoctoral research fellow
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
Boston, Massachusetts
Gabriel Jabbour, MS (he/him/his)

Research Student
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
Boston, Massachusetts
JG

Jorge L. Gomez-Mayorga

Research Fellow
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
Boston, Massachusetts
TM

Tim J. Mandigers

MD, PhD student
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
Cambridge, Massachusetts
Randall A. Bloch, MD

Research Fellow
St. Elizabeth's Medical Center
Boston, Massachusetts
Grace J. Wang, MD, MS

Associate Professor of Surgery
University of Pennsylvania Health System
Philadelphia, Pennsylvania
BN

Brian Nolan

Senior Author(s)

Marc L. Schermerhorn, MD (he/him/his)

Chief of Vascular and Endovascular Surgery
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
Boston, Massachusetts

Objectives: Renal failure is known to be a predictor of adverse outcomes in carotid revascularization, and there has been debate as to whether any revascularization should be performed in patients with severe CKD or those on dialysis.

Methods: VQI patients undergoing TCAR, tfCAS, or CEA between 2016 and 2023 with eGFR < 30 ml/min/1.73m2 or on dialysis (HD) were included. Patients were divided into cohorts based on procedure. Additional subgroup analysis was also done for patients on HD only. The primary outcome was perioperative stroke/death/MI (SDM). The secondary outcomes included perioperative death, stroke, MI, CNI, and stroke/death. Inverse probability of treatment weighting (IPW) was performed based on treatment assignment to TCAR, tfCAS, and CEA patients and adjusted for demographics, comorbidities, and pre-op symptoms. Chi-square and multivariable logistic regression analysis were used to evaluate the association of procedure with perioperative outcomes in the weighted cohort. 5-year survival was evaluated using Kaplan-Meier and weighted Cox regression.

Results: 13042 patients with eGFR of < 30 (2355 on HD) underwent TCAR (3730 with 727 HD), tfCAS (2047, 410 HD) or CEA (7265, 1218 HD) during the study period. In the eGFR < 30 and HD group, compared with TCAR, CEA had a trend towards higher odds of stroke/death/MI (3.3%vs3.2%, aOR1.24[0.98,1.58],p=.078), and higher odds of MI (1.3%vs0.9%,aOR1.92[1.92,2.95],p=.003). There were also higher rates of CNI (1.9%vs0.3%,aOR5.18[2.81,-9.55]p <.001). However, there were similar rates of stroke and death. Subgroup analysis in the HD-only group was similar to the primary analysis. Compared to TCAR, rates of stroke/death/MI, stroke, death, MI, and stroke/death were all higher for tfCAS in both overall and the HD-only groups. (Table I)

In both groups, the long-term survival was similar for CEA and TCAR (eGFR < 30: 82% vs 81%%,aHR1,p=.9, only HD:72%% vs 72%%,aHR1.08,p=.95) and worse for tfCAS (eGFR < 30: 75% vs 81%, aHR1.52,p <.001, only HD: 63%vs 72%%, aHR1.45,p=.005) (Figure I)

Conclusions: CEA and TCAR had similar rates of stroke and death and are both a reasonable choice in this population, however, TCAR may be better in patients with increased risk of MI. It is also apparent that even after weighting for symptom status tfCAS patients were more likely to have worse outcomes. Finally, while patients with reduced eGFR have worse outcomes than their healthy peers, this analysis shows that after all revascularization procedures, the majority of patients do survive long enough to benefit from the potential stroke risk reduction provided by revascularization.