Advertisement

Female Gender Increases Risk of Stroke and Readmission after CEA and CAS

Published:November 01, 2021DOI:https://doi.org/10.1016/j.jvs.2021.10.034

      ARTICLE HIGHLIGHTS

      • Type of Research: Retrospective review of prospectively collected National Surgical Quality Improvement Program (NSQIP) data.
      • Key Findings: Carotid endarterectomy (CEA) or carotid artery stenting (CAS) for treatment of carotid artery stenosis in 106,568 patients demonstrated that female gender is associated with significantly increased rates of 30-day CVA/stroke in asymptomatic (13%, p=0.005) and symptomatic (32%, p=0.034) patients as well as readmission in asymptomatic patients (11%, p=0.001).
      • Take home Message: In patients that undergo carotid intervention, female gender is associated with significantly increased rates of postoperative CVA/stroke in asymptomatic and symptomatic patients as well as readmission in asymptomatic patients
      • Table of Contents Summary
      • Female gender was associated with significantly increased rates of 30-day postoperative CVA/stroke in asymptomatic and symptomatic patients as well as readmission in asymptomatic patients following CEA or CAS in this retrospective study of 106,568 patients. The authors suggest that there are significant differences in gender-based postoperative outcomes in surgical management of cerebrovascular disease and recommend adequate representation of female patients in studies to better understand gender-based disparities in carotid intervention.

      ABSTRACT

      Objectives

      Carotid endarterectomy (CEA) has historically demonstrated a higher rate of perioperative adverse events for female patients. However, recent evidence suggests similar outcomes for CEA between genders. In contrast, fewer studies have examined gender in carotid artery stenting (CAS). Using contemporary data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we aim to determine if gender impacts differences in postoperative complications in patients who undergo CEA or CAS.

      Methods

      The ACS NSQIP database was queried from 2005-2017 using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes for retrospective review. Patients with carotid intervention (CEA or CAS) were stratified into asymptomatic vs symptomatic cohorts to determine the effect of gender on 30-day postoperative outcomes. Symptomatic patients were defined as those with perioperative transient cerebral ischemic attack or stenosis of carotid artery with cerebral infarction. Descriptive statistics were calculated. Risk-adjusted odds of 30-day postoperative outcomes were calculated using multivariate regression analysis with fixed effects for age, race, and comorbidities.

      Results

      There were 106,568 patients with CEA or CAS (104,412 CEA and 2,156 CAS). Average age was 70.9 years old and female patients accounted for 39.9% of the population. For asymptomatic patients that underwent CEA or CAS, female gender was associated with significantly higher rates of CVA/stroke (13%, p=0.005), readmission (10%, p=0.004), bleeding complication (32%, p=0.001), and UTI (54%, p=0.001) as well as less infection (26%, p=0.001). In the symptomatic cohort, female gender was associated with significantly higher rates of CVA/stroke (32%, p=0.034), bleeding complication (203%, p=0.001), and UTI (70%, p=0.011), while female gender was associated with a lower rate of pneumonia (39%, p=0.039). Subset analysis found that, compared to male patients, female patients <75yo have an increased rate of CVA/stroke (21%, p=0.001) and readmission (15%, p<0.001), while female patients ≥75yo did not. In asymptomatic and symptomatic patients that underwent CEA, female gender was associated with significantly higher rates of CVA/stroke (13%, p=0.006 and 31%, p=0.044, respectively), but this finding was present not in patients undergoing CAS.

      Conclusion

      In patients undergoing carotid intervention, female gender was associated with significantly increased rates of postoperative CVA/stroke in the asymptomatic and symptomatic cohorts as well as readmission in the asymptomatic cohort. Female gender was associated with higher rates of CVA/stroke following CEA, but not CAS. We recommend that randomized control trials ensure adequate representation of female patients to better understand gender-based disparities in carotid intervention.
      To read this article in full you will need to make a payment
      SVS Member Login
      Society Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      BIBLIOGRAPHY

        • Go A.S.
        • Mozaffarian D.
        • Roger V.L.
        • Benjamin E.J.
        • Berry J.D.
        • Borden W.B.
        • et al.
        Executive summary: heart disease and stroke statistics - 2013 Update: a report from the American Heart Association.
        Circulation. 2013; 127: 143-152
        • Berger J.S.
        • Roncaglioni M.C.
        • Avanzini F.
        • Pangrazzi I.
        • Tognoni G.
        • Brown D.L.
        Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials.
        Public Health. 2006; 295: 306-313
        • Howard V.J.
        • Lutsep H.L.
        • Mackey A.
        • Demaerschalk B.M.
        • Sam A.D.
        • Gonzales N.R.
        • et al.
        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: 530-537
        • Alamowitch S.
        • Eliasziw M.
        • Barnett H.J.M.
        The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease.
        Stroke. 2005; 36: 27-31
      1. Trial C. Randomised Trial of Endarterectomy for Recently Symptomatic Carotid Stenosis : Final Results of the MRC European Carotid Surgery Trial (ECST). 1998;351(9113):351–352.

        • De Rango P.
        • Brown M.M.
        • Didier L.
        • Howard V.J.
        • Moore W.S.
        • Paciaroni M.
        • et al.
        Management of carotid stenosis in women consensus document.
        Neurology. 2013; 80: 2258-2268
        • Badheka A.O.
        • Chothani A.
        • Panaich S.S.
        • Mehta K.
        • Patel N.J.
        • Deshmukh A.
        • et al.
        Impact of symptoms, gender, co-morbidities, and operator volume on outcome of carotid artery stenting (from the nationwide inpatient sample [2006 to 2010]).
        Am J Cardiol. 2014; 114: 933-941
        • Choi J.H.
        • Pile-Spellman J.
        • Brisman J.L.
        US nationwide trends in carotid revascularization: Hospital outcome and predictors of outcome from 1998 to 2007.
        Acta Neurol Scand. 2014; 129: 85-93
        • Bennett K.M.
        • Scarborough J.E.
        Carotid artery stenting is associated with a higher incidence of major adverse clinical events than carotid endarterectomy in female patients.
        J Vasc Surg. 2017; 66: 794-801
        • Rockman C.B.
        • Garg K.
        • Jacobowitz G.R.
        • Berger J.S.
        • Mussa F.F.
        • Cayne N.S.
        • et al.
        Outcome of carotid artery interventions among female patients, 2004 to 2005.
        J Vasc Surg. 2011; 53: 1457-1464
        • Bisdas T.
        • Egorova N.
        • Moskowitz A.J.
        • Sosunov E.A.
        • Marin M.L.
        • Faries P.L.
        • et al.
        The impact of gender on in-hospital outcomes after carotid endarterectomy or stenting.
        Eur J Vasc Endovasc Surg. 2012; 44: 244-250
        • Mayor J.M.
        • Salemi J.L.
        • Dongarwar D.
        • Salihu H.M.
        • Montero-Baker M.
        • Mills J.L.
        • et al.
        Sex-Based Differences in Ten-Year Nationwide Outcomes of Carotid Revascularization.
        J Am Coll Surg. 2019; 229 (e4): 38-46
        • Casana R.
        • Malloggi C.
        • Tolva V.
        • Odero A.J.
        • Bulbulia R.
        • Halliday A.
        • et al.
        Three-year outcomes after carotid artery revascularization: Gender-related differences.
        Vascular. 2019; 27: 459-467
        • Kuy SreyRam
        • Dua A.
        • Desai S.
        • Rossi P.J.
        • Seabrook G.R.
        • Lewis B.D.
        • et al.
        Carotid Endarterectomy National Trends Over A Decade: Does gender matter?.
        Ann Vasc Surg. 2014; 28: 887-892
        • Rockman C.B.
        • Castillo J.
        • Adelman M.A.
        • Jacobowitz G.R.
        • Gagne P.J.
        • Lamparello P.J.
        • et al.
        Carotid endarterectomy in female patients: Are the concerns of the asymptomatic carotid atherosclerosis study valid?.
        J Vasc Surg. 2001; 33: 236-241
        • Jim J.
        • Dillavou E.D.
        • Upchurch G.R.
        • Osborne N.H.
        • Kenwood C.T.
        • Siami F.S.
        • et al.
        Gender-specific 30-day outcomes after carotid endarterectomy and carotid artery stenting in the Society for Vascular Surgery Vascular Registry.
        J Vasc Surg. 2014; 59: 742-748
        • Manuel J.I.
        Racial/Ethnic and Gender Disparities in Health Care Use and Access.
        Health Serv Res. 2018; 53: 1407-1429
        • Buratti L.
        • Balestrini S.
        • Avitabile E.
        • Altamura C.
        • Vernieri F.
        • Viticchi G.
        • et al.
        Sex-associated differences in the modulation of vascular risk in patients with asymptomatic carotid stenosis.
        J Cereb Blood Flow Metab. 2015; 35: 684-688
        • Nguyen L.L.
        • Henry A.J.
        Disparities in vascular surgery: Is it biology or environment?.
        J Vasc Surg. 2010; 51: 1-10
        • Vogel T.R.
        • Kruse R.L.
        • Kim R.J.
        • Dombrovskiy V.Y.
        Racial and Socioeconomic Disparities After Carotid Procedures.
        Vasc Endovascular Surg. 2018 Jul; 52: 330-334
        • McGinigle K.L.
        • Browder S.E.
        • Strassle P.D.
        • Shalhub S.
        • Harris L.M.
        • Minc S.D.
        Sex Related Disparities in Intervention Rates and Type of Intervention in Patients with Aortic and Peripheral Arterial Diseases in the National Inpatient Sample Database.
        J Vasc Surg. 2020; S0741-5214 (32506-4)
        • Nejim B.
        • Obeid T.
        • Arhuidese I.
        • Hicks C.
        • Wang S.
        • Canner J.
        • et al.
        Predictors of perioperative outcomes after carotid revascularization.
        J Surg Res. 2016; 204: 267-273
        • Hoel A.W.
        • Kayssi A.
        • Brahmanandam S.
        • Belkin M.
        • Conte M.S.
        • Nguyen L.L.
        Under-representation of women and ethnic minorities in vascular surgery randomized controlled trials.
        J Vasc Surg. 2009; 50: 349-354
        • Bisdas T.
        • Egorova N.
        • Moskowitz A.J.
        • Sosunov E.A.
        • Marin M.L.
        • Faries P.L.
        • et al.
        European Journal of Vascular and Endovascular Surgery The Impact of Gender on In-hospital Outcomes after Carotid Endarterectomy or Stenting.
        Eur J Vasc Endovasc Surg. 2012; 44: 244-250
        • Brinza E.K.
        • Armstrong E.J.
        Sex-related differences in outcomes after vascular interventions.
        Vascular Medicine. 2018; 23: 560-569
        • Marulanda-londoño E.
        • Chaturvedi S.
        Carotid stenosis in women: time for a reappraisal.
        Stroke Vasc Neurol. 2016; 1: 192-196
      2. Casana R, Malloggi C, Tolva VS, Odero A, Bulbulia R, Halliday A, Silani V, Parati G. Do Women Have a Higher Risk of Adverse Events after Carotid Revascularization? Carotid Artery - Gender and Health. Nov 2018.

        • Chou E.L.
        • Sgroi M.D.
        • Chen S.L.
        • Kuo I.J.
        • Kabutey N.
        • Fujitani R.M.
        Influence of gender and use of regional anesthesia on carotid endarterectomy outcomes.
        J Vasc Surg. 2019; 64: 9-14
        • Norris C.M.
        • Spertus J.A.
        • Jensen L.
        • Johnson J.
        • Hegadoren K.M.
        • Ghali W.A.
        • et al.
        Sex and Gender Discrepancies in Health-Related Quality of Coronary Artery Disease.
        Circ Cardiovasc Qual Outcomes. 2008 Nov; 1: 123-130
        • Schermerhorn M.L.
        • Fokkema M.
        • Goodney P.
        • Dillavou E.D.
        • Jim J.
        • Kenwood C.T.
        • Siami F.S.
        • White R.A.
        • SVS Outcomes Committee
        The impact of Centers for Medicare and Medicaid Services high-risk criteria on outcome after carotid endarterectomy and carotid artery stenting in the SVS Vascular Registry.
        J Vasc Surg. 2013 May; 57: 1318-1324
        • Bennett I.C.
        American College of Surgeons National Surgical Quality Improvement Program: first Australian experience.
        ANZ J Surg. 2019; 89: 459-460
        • Alhaidar M.
        • Algaeed M.
        • Amdur R.
        • Algahtani R.
        • Majidi S.
        • Sigounas D.
        Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting for Carotid Stenosis in the ACS-NSQIP Database.
        J Vasc Interv Neurol. 2018; 10: 52-56
        • Bonati L.H.
        • Dobson J.
        • Algra A.
        • Branchereau A.
        • Chatellier G.
        • Fraedrich G.
        • et al.
        • Carotid Stenting Trialists' Collaboration
        Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data.
        Lancet. 2010; 376: 1062-1073
      3. Atherosclerosis EC for the AC, Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA. 1995;273(18):1421–1428.

        • Dakour Aridi H.
        • Locham S.
        • Nejim B.
        • Malas M.B.
        Comparison of 30-day readmission rates and risk factors between carotid artery stenting and endarterectomy.
        J Vasc Surg. 2017; 66 (e7): 1432-1444
        • Cole T.S.
        • Mezher A.W.
        • Catapano J.S.
        • Godzik J.
        • Baranoski J.F.
        • Nakaji P.
        • et al.
        Nationwide Trends in Carotid Endarterectomy and Carotid Artery Stenting in the Post-CREST Era.
        Stroke. 2020; : 579-587
        • Edla S.
        • Atti V.
        • Kumar V.
        • Tripathi B.
        • Neupane S.
        • Nalluri N.
        • et al.
        Comparison of nationwide trends in 30-day readmission rates after carotid artery stenting and carotid endarterectomy.
        J Vasc Surg. 2020; 71 (e9): 1222-1232
        • Hintze A.J.
        • Greenleaf E.K.
        • Schilling A.L.
        • Hollenbeak C.S.
        Thirty-day Readmission Rates for Carotid Endarterectomy Versus Carotid Artery Stenting.
        J Surg Res. 2019; 235: 270-279
        • Naylor A.R.
        Age and carotid intervention outcomes.
        Lancet. 2020; 387: 2014-2016