Contemporary Evaluation Of Treatment Differences Among Males And Females Undergoing Carotid Revascularization
Christina Cui, MAS, Sina Zarrintan, MD, Rebecca Marmor, MD, MAS, James Nichols, MD, Luis Cajas-Monson, MD, MPH, Mahmoud Malas, MD, MHS, FACS.
University of California, San Diego, La Jolla, CA, USA.
Objective: Current recommendations for carotid revascularization apply to both males and females. Sub-analysis of large randomized clinical trials (RCTs), such as CREST, have found increased periprocedural risk among females undergoing stenting over carotid endarterectomy (CEA). These conclusions, however, may be due to female underrepresentation within RCTs. Earlier studies also did not include transcarotid artery revascularization with flow reversal (TCAR). The purpose of this study is to evaluate whether treatment differences persist between males and females in the real-world setting.
Methods: We performed a retrospective analysis of the Vascular Quality Initiative CEA and carotid stenting registries from September 2016-November 2019. Outcomes after TCAR, TFCAS, and CEA were compared within each sex. Multivariable logistic regression analysis was used to model within each sex the relationship between each procedure and outcome of interest (in-hospital any stroke, stroke or death, and stroke, death, MI) using backward selection. We also performed a sub-analysis, stratifying patients by symptom status.
Results: A total of 75,538 patients were included, of which 28,960 (38.3%) were females (75.3% CEA, 13.9% TFCAS, 10.9% TCAR) and 46,578 (61.7%) were males (72.4% CEA, 15.7% TFCAS, 11.9% TCAR). TFCAS females had increased odds of in-hospital stroke/death/MI [OR (95%CI): 2.02 (1.58-2.58), p<0.001] while TCAR females had comparable odds of major adverse events when compared to CEA females. However, TCAR females did experience increased odds of post-operative TIA [OR (95%CI): 1.91 (1.09-3.35), p=0.025] when compared to CEA females. TFCAS males also experienced increased odds of in-hospital stroke/death/MI [OR (95%CI): 1.62 (1.35-1.95), p<0.001] while TCAR males performed similarly when compared to CEA males. Similar trends were identified on stratified analysis by symptomatic status.
Conclusion: For both males and females, TFCAS is associated with increased odds of postoperative and one-year adverse events. TCAR has similar outcomes in comparison to CEA regardless of sex and symptomatic status. This contemporary cohort analysis suggests that males and females can be treated with similar revascularization algorithm.
| Females (n=28,960, 38.3%) | Males (n=46,578, 61.7%) | |||||||||
| TFCAS (n=4015, 13.86%) | TCAR (n=3142, 10.85%) | CEA (n=21803, 75.29%) | TFCAS (n=7319, 15.71%) | TCAR (n=5519, 11.85%) | CEA (n=33740, 72.44%) | |||||
| OR (95% CI) | P-Value | OR (95% CI) | P-Value | OR (95% CI) | OR (95% CI) | P-Value | OR (95% CI) | P-Value | OR (95% CI) | |
| Stroke | 1.72 (1.24, 2.40) | 0.001 | 0.99 (0.64, 1.54) | 0.982 | Reference | 1.22 (0.92, 1.61) | 0.162 | 1.24 (0.93, 1.66) | 0.147 | Reference |
| TIA | 1.94 (1.14, 3.31) | 0.015 | 1.91 (1.09, 3.35) | 0.025 | Reference | 1.51 (0.99, 2.32) | 0.057 | 1.43 (0.90, 2.27) | 0.126 | Reference |
| Death | 3.82 (2.60, 5.59) | < 0.001 | 1.16 (0.65, 2.1) | 0.612 | Reference | 4.07 (3.05, 5.45) | < 0.001 | 1.27 (0.76, 2.13) | 0.369 | Reference |
| MI | 0.85 (0.53, 1.37) | 0.506 | 0.76 (0.41, 1.41) | 0.384 | Reference | 0.82 (0.57, 1.17) | 0.265 | 0.51 (0.33, 0.79) | 0.003 | Reference |
| Stroke/TIA | 1.79 (1.31, 2.45) | < 0.001 | 1.20 (0.82, 1.75) | 0.353 | Reference | 1.3 (1.02, 1.66) | 0.037 | 1.28 (0.99, 1.66) | 0.057 | Reference |
| Stroke/Death | 2.51 (1.93, 3.26) | < 0.001 | 0.96 (0.64, 1.43) | 0.833 | Reference | 1.92 (1.56, 2.38) | < 0.001 | 1.28 (0.97, 1.67) | 0.077 | Reference |
| Stroke/Death/MI | 2.02 (1.58, 2.58) | < 0.001 | 0.81 (0.58, 1.14) | 0.232 | Reference | 1.62 (1.35, 1.95) | < 0.001 | 1.03 (0.8, 1.32) | 0.838 | Reference |
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