The Impact of Race on Outcomes after Carotid Endarterectomy in the U.S.A.
Alexander B. Pothof, MD MS1, Peter A. Soden, MD1, Sarah E. Deery, MD MPH1, Thomas F. O'Donnell, MD1, Gert J. de Borst, MD2, Marc L. Schermerhorn, MD1.
1BIDMC, Boston, MA, USA, 2UMC Utrecht, Utrecht, Netherlands.
Objective: Black patients undergoing carotid endarterectomy (CEA) are more likely symptomatic at presentation and have more comorbidities. However, the impact of racial disparities on outcomes after CEA is largely unknown.
Methods: We identified CEA patients in the Vascular Quality Initiative (VQI) registry (2012-2017) and compared them by race (Black vs. White). All other non-White races (891, 1.4%) and Hispanics (2222, 3.4%) were excluded. We used multilevel logistic regression to account for differences in demographics and comorbidities, clustering at the center level. We assessed late survival using multivariable Cox regression. The primary outcome was perioperative stroke/death.
Results: We included 57,622 CEA patients; 2909 (5.0%) were Black, of whom 983 (34%) were symptomatic. Of the 54,713 White patients, 16,132 (30%) were symptomatic. Compared to White patients, Black patients had more comorbidities, and were less likely to be operated on in a high volume hospital, or by a high volume surgeon (Table I). Perioperative stroke/death was comparable between Black and White patients (symptomatic: 2.8% vs. 2.2%, P=.2; asymptomatic: 1.6% vs. 1.3%, P=.2). On multilevel logistic regression, race was not associated with perioperative stroke/death (OR 1.0 [95% CI: 0.8-1.3] P=.98), however Black patients experienced lower adjusted long-term mortality compared to White patients (HR 0.8 [0.7-0.9] P=.01).
Conclusion: Despite the greater prevalence of vascular risk factors in Black patients and racial inequalities in surgical treatment, rates of perioperative stroke/death and unadjusted survival were similar between White and Black patients. However, after adjustment, which included the identified racial disparities, Black patients experienced lower adjusted long-term mortality after CEA. Addressing these racial inequalities could improve the efficacy of CEA for Black patients.
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