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 PVSS4. Revascularization of Asymptomatic Carotid Stenosis Is Not Appropriate In Patients on Dialysis

Joseph Sidaoui, Theodore H. Yuo, Luke K. Marone, Larry Fish, Michel Makaroun, Rabih Chaer
Surgery, UPMC, Pittsburgh, PA.
 
OBJECTIVES: Outcomes of carotid endarterectomy (CEA) or angioplasty and stenting (CAS) for asymptomatic disease in patients on dialysis are not well characterized, with questionable stroke prevention and survival. This study reports outcomes of carotid revascularization in asymptomatic U.S. dialysis patients.
 
METHODS: Using U.S. Renal Data System (USRDS) databases, we identified all dialysis patients who underwent CEA and CAS for asymptomatic disease from 2005-2008. CEA and CAS were identified by CPT codes, and symptom status and comorbidities by ICD9 codes. Primary outcomes were stroke, cardiac complications and death at 30 days, and at 1 and 3 years. Predictors of mortality were identified using regression models.
 
RESULTS: Out of 738,561 dialysis patients, 2131 asymptomatic patients had carotid revascularization (1805 CEA, 326 CAS). The mortality rate was 4.7% at 30 days (4.6% CEA, 4.9% CAS, p=0.81), and 24.6% at 1 year (23.8% CEA, 29.7% CAS, p=0.054). Kaplan Meier estimates of survival were 75.1% at 1 year (75.9% CEA, 70.7% CAS, p=0.17), and 43.1% at 3 years (43.4% CEA, 41.7% CAS, p=0.58). Stroke rate was 6.5% at 30 days (6.4% CEA, 6.8% CAS, p=0.81) and 13.6% at 1 year (13.3% CEA, 15.3% CAS, p=0.43). Cardiac complications occurred in 22% of patients (3.2%MI) at 30 days (22.2% CEA, 20.7% CAS, p=0.69). The combined stroke or death rate was 10.2% at 30 days (10.0% for CEA, and 11.1% for CAS, p=0.56), and 33.5% at 1 year (32.2% CEA, 40.6% CAS, p=0.013). Age>70, time on dialysis and history of transplant were predictive of mortality. Compared to the general population, patients who underwent CEA or CAS had increased mortality (p<.001).
 
CONCLUSIONS: Patients on dialysis have high perioperative and long-term stroke or death rates following CEA or CAS for asymptomatic stenosis. Carotid intervention in these patients appears to be inappropriate.
 
AUTHOR DISCLOSURES: R. Chaer: Nothing to disclose; L. Fish: Nothing to disclose; M. Makaroun: Nothing to disclose; L. K. Marone: Nothing to disclose; J. Sidaoui: Nothing to disclose; T. H. Yuo: Nothing to disclose.
 
Comorbidities and risk factors by type of procedure
CEA N(%)​ ​​CAS N(%) ​P-value
Age (in years, mean±SD) Sex (Male) Diabetes History of transplant Ischemic heart disease PVD Hypertension Smokers Presence of neoplasm Time on dialysis (in years, mean±SD) BMI (mean±SD) ​ ​69.1 (9.46) 1116 (60.3%) 997 (55.5%) 261 (14.1%) 399 (39.8%) 447 (24.9%) 1545 (85.9%) 149 (8.3%) 92 (5.1%) 3.5 (3.95) 27.8 (6.42) ​69.1 (8.98) 213 (64.0%) 189 (57.6%) 38 (11.4%) 61 (35.5%) 94 (28.7%) 276 (84.2%) 18 (5.5%) 22 (6.7%) 3.2 (3.60) 28.0 (6.64) ​0.99 0.21 0.47 0.19 0.28 0.15 0.40 0.08 0.24 0.30 0.71
 
Posted March 2013

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