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Impact Of EGFR On Outcomes Of Carotid Revascularization Interventions: A Comparative Analysis
Nishita R. Vootukuru, BS;
UCSD, La Jolla, CA, USA

OBJECTIVES: Carotid revascularization procedures in patients with Chronic Kidney Disease (CKD) are considered high risk. This study addresses the knowledge gap surrounding outcomes for CKD patients undergoing carotid artery endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR). The aim is to determine the optimal approach for carotid revascularization stratified by CKD severity.METHODS: We identified all patients who had undergone CEA and CAS from September 2016 to 2023 in the VQI. Comparison groups were based on CKD stages in accordance with the National Kidney Foundationís Kidney Disease Outcomes Quality Initiative, as follows: Stage 1, eGFR > 90 mL/min/1.73 m≤; Stage 2, eGFR 60-89 mL/min/1.73 m≤; Stage 3/moderate, eGFR 30-59 mL/min/1.73 m≤; Stage 4/severe, eGFR 15-29 mL/min/1.73 m≤; Stage 5/ESRD, eGFR < 15 mL/min/1.73 m≤ or dialysis. Stage 5 was excluded. We performed logistic regression to compare procedures. Our primary outcomes were in-hospital stroke, death, and combined stroke/death. Secondary outcomes were transient ischemic attack (TIA), myocardial infarction (MI), combined stroke/death/MI, and extended length of stay (eLOS).RESULTS: Our cohort consisted of 114,384 patients undergoing CEA (30.5% moderate, 2.5% severe), 23709 patients undergoing TFCAS (31.3% moderate, 2.6% severe), and 42,432 patients undergoing TCAR (35.4% moderate, 2.5% severe). After adjusting for confounders, we observed adverse outcomes in CEA for death, MI, eLOS, and stroke/death/MI in both moderate and severe patients. For TFCAS, patients with severe CKD had significant adverse outcomes, in death, MI, and stroke/death/MI. For TCAR, MI and stroke/death/MI were significant in patients with moderate CKD, and death, MI, stroke/death, eLOS, and stroke/death/MI in patients with severe CKD (Table I). CEA outperformed than TFCAS for stroke, death, stroke/death, stroke/death/MI, and eLOS in patients with moderate CKD, and for death and stroke/death in patients with severe CKD. CEA outperformed TCAR for stroke, stroke/death, and eLOS in patients with moderate CKD, and for death, MI, stroke/death, eLOS in patients with severe CKD(Table I).CONCLUSIONS: Carotid revascularization poses a real risk for patients with CKD undergoing any carotid revascularization, namely for severe patients. However, CEA may be a safer option compared to TFCAS and TCAR, for patients with both moderate and severe CKD.

Table I. Multivariable outcomes for CEA, TFCAS, and TCAR. aOR = adjusted odds ratio, CI= confidence
CEATFCASTCAR
aOR (CI 95%); p-valueaOR (CI 95%); p-value; [compared to CEA aOR (CI 95%); p-value]
moderateseveremoderateseveremoderatesevere
stroke1.05(0.93, 1.2); 0.3920.91(0.64, 1.3); 0.5961.08(0.92, 1.27); 0.355; [1.8 (1.4, 2.2); <0.001***]1.32(0.84, 2.07); 0.234; [2.0(1.1, 3.7); 0.015]1.15 (0.96, 1.38); 0.12;[1.4(1.1, 1.7); 0.001**]1.06(0.65, 1.76); 0.8;[1.2(0.7, 2.2); 0.462]
death1.33(1.05,1.69); 0.018*1.96(1.24, 3.10); 0.004**1.25(0.97, 1.61); 0.091; [3.0 (2.1, 4.3); <0.001***]1.76(1.01, 3.06); 0.043*;[2.0(0.9, 4.3); 0.09]1.31(0.91, 1.87); 0.134;[1.0 (0.8, 1.4); 0.79]1.12(2.47, 6.85); <0.001***;[2.6 (1.3, 5.3); 0.007**]
TIA0.99(0.81,1.21); 0.921.05(0.60,1.88); 0.8471.02(0.75, 1.40); 0.893; [1.4(0.9, 2.2); 0.156]0.94(0.38, 2.34); 0.899;[0.5(0,1, 1.8); 0.295]0.99(0.73, 1.32); 0.926;[1.0 (0.7, 1.4); 0.94]1.18(0.55, 2.57); 0.659;[1.0 (0.8, 1.4); 0.95]
MI1.22(1.03,1.45); 0.019**2.48(1.83, 3.10); <0.001***1.37(0.93, 2.01); 0.117; [0.8(0.5, 1.2); 0.323]2.71(1.38, 5.33); 0.004**;[0.7(0.3, 1.4); 0.32]1.83 (1.36, 2.48); <0.001***;[0.6 (0.5, 0.8); 0.49]2.43(1.30, 4.53); 0.005**;[0.4(0.2, 0.8); 0.007**]
stroke/death1.09(0.97,1.22); 0.1281.14(0.85, 1.55); 0.3671.20(1.01, 1.43); 0.08; [2.3(1.8, 3.0); <0.001***]1.41 (0.95, 2.12); 0.09;[1.8(1.0, 3.1); 0.034]1.17(0.99, 1.38)); 0.06;[1.3(1.0, 1.5); 0.019*]1.77(0.99, 1.38); 0.002**;[1.7(1.0, 2.7); 0.039*]
eLOS1.03(0.99, 1.08); 0.1021.42(1.30, 1.56); <0.001***0.93(0.85, 1.02); 0.106; [1.3(1.1, 1.5); <0.001***]1.08(0.89, 1.31); 0.444;[1.1 (0.9, 1.6); 0.281]0.99(0.95, 1.04); 0.8;[0.9(0.8, 1.0);0.015*]1.24(1.08, 1.43); 0.002**;[0.9(0.7, 1.0); 0.09]
stroke/death/MI1.13(1.03, 1.24); 0.012*1.49(1.18, 1.89); <0.001***1.19(1.01, 1.42); 0.06; [1.8 (1.4, 2.2); <0.001***]1.49(1.04, 2.13); 0.034**;[1.4 (0.9, 2.1); 0.111]1.25(1.08, 1.45); 0.002**;[0.9 (0.8, 1.0); 0.505]1.91 (1.35, 2.68); <0.001***;[1.2(0.8, 1.9); 0.386]


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