Black Patients Are More Likely to Undergo Transfemoral Carotid Artery Stenting for Treatment of Carotid Artery Stenosis

Abstract

INTRODUCTION: Black race has been associated with worse outcomes after carotid endarterectomy (CEA) or transfemoral carotid artery stenting (TFCAS), but few studies have focused on procedural selection in these patients. We aimed to compare rates of TFCAS vs CEA in Black and White patients using the Vascular Quality Initiative (VQI) database. METHODS: We included subjects who underwent CEA and TFCAS in VQI between 2003-2021. Patients were divided based on race (Black or White). The primary outcome of interest was the choice of CEA or TFCAS. Secondary outcomes included in-hospital death, stroke, and myocardial infarction (MI). Propensity score matching was utilized to create a balanced cohort and univariate methods were utilized to compare outcomes. RESULTS: A total of 141,191 carotid revascularizations were performed [125,244 (88.7%) CEA, 15,947 (11.3%) TFCAS] in 133,840 (94.8%) White patients and 7,351 (5.2%) Black patients. Propensity matching achieved a well-matched cohort of 5,574 pairs. After matching, Black patients demonstrated higher likelihood of having undergone TFCAS (4.9% vs 3.7%, OR 1.36, 95% CI 1.04-1.78, p = 0.03) as well as higher risk of in-hospital stroke (1.7% vs 1.2%, OR 1.40, 95% CI 1.04-1.90, p = 0.03) driving stroke/death (2.0% vs 1.4%, OR 1.43, 95% CI 1.10-1.87) and stroke/death/MI (2.4% vs 1.8%, OR 1.36, 95% CI 1.04-1.77) (Table 1). Table 1. - Propensity-Matched Outcomes of Carotid Revascularization by Race Variable White (5,574, 50%) Black (5,574, 50%) Odds ratio (95% CI) p Value TFCAS 205 (3.7%) 275 (4.9%) 1.36 (1.04-1.78) 0.03 Death 16 (0.3%) 23 (0.4%) 1.44 (0.78-2.66) 0.25 Stroke 68 (1.2%) 95 (1.7%) 1.40 (1.04-1.90) 0.03 MI 22 (0.4%) 22 (0.4%) 1.00 (0.52-1.92) 1.00 Stroke/death 80 (1.4%) 114 (2.0%) 1.43 (1.10-1.87) 0.008 Stroke/death/MI 98 (1.8%) 132 (2.4%) 1.36 (1.04-1.77) 0.02 CONCLUSION: Black race was independently associated with selection for TFCAS compared to CEA as well as increased stroke risk after propensity score matching. Given that CEA is the gold standard for revascularization due to the perioperative stroke risk of TFCAS, this represents a potential contributor to racial disparities.