Int J Angiol
DOI: 10.1055/s-0040-1712506
Original Article

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

Young Erben
1  Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
,
Yupeng Li
2  Department of Political Science and Economics, Rowan University, Glassboro, New Jersey
,
Joao A. Da Rocha-Franco
1  Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
,
Rabih G. Tawk
3  Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
,
Kevin M. Barrett
4  Department of Neurology, Mayo Clinic, Jacksonville, Florida
,
William D. Freeman
3  Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
4  Department of Neurology, Mayo Clinic, Jacksonville, Florida
,
Michelle Lin
4  Department of Neurology, Mayo Clinic, Jacksonville, Florida
,
Josephine F. Huang
4  Department of Neurology, Mayo Clinic, Jacksonville, Florida
,
David Miller
5  Department of Radiology, Mayo Clinic, Jacksonville, Florida
,
Houssam Farres
1  Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
,
Thomas G. Brott
4  Department of Neurology, Mayo Clinic, Jacksonville, Florida
,
James F. Meschia
4  Department of Neurology, Mayo Clinic, Jacksonville, Florida
,
Albert G. Hakaim
1  Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
› Author Affiliations

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.

Article Highlights

Higher peri-operative TIA/stroke in female asymptomatic patients after CAS and higher long-term mortality in male asymptomatic patients after CAS. Mortality is directly related to prior/current smoking history, coronary artery disease, chronic obstructive pulmonary disease, higher American Society of Anesthesiologists (ASA) physical status classification and low hemoglobin baseline levels.


Type of Research

Multicenter review of the vascular quality initiative (VQI) database regarding carotid stenting (CAS) in asymptomatic patients.


Key Findings

Higher perioperative TIA/stroke in female asymptomatic patients after CAS and higher long-term mortality in male asymptomatic patients after CAS. Mortality is directly related to prior/current smoking history, coronary artery disease, chronic obstructive pulmonary disease, higher American Society of Anesthesiologists (ASA) physical status classification, and low hemoglobin baseline levels.


Take Home Message

Smoking status, coronary artery disease, chronic obstructive pulmonary disease, ASA physical status classification, and low hemoglobin levels should be considered prior to offering male asymptomatic patients CAS due to higher mortality risk on long-term follow-up.


Table of Contents Summary

In this multicenter review of VQI regarding CAS in asymptomatic patients, smoking status, coronary artery disease, chronic obstructive pulmonary disease, ASA physical status classification, and low hemoglobin levels should be carefully characterized prior to offering male patients CAS due to higher mortality risk on long-term follow-up.




Publication History

Publication Date:
16 September 2020 (online)

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