Dialysis-dependent Patients Have Increased Risk of Myocardial Infarction and Perioperative Death Following Carotid Revascularization Using Transcarotid Artery Revascularization

Abstract

Dialysis-dependent patients have been reported to have high rates of stroke and death following carotid revascularization; however, recent data suggests that outcomes for the treatment of carotid stenosis in dialysis-dependent patients may be better than previously surmised. The effect of dialysis dependence on outcomes following transcarotid artery revascularization (TCAR) remains unclear. We aimed to study outcomes following the treatment of symptomatic and asymptomatic carotid stenosis using TCAR among dialysis-dependent patients. The Vascular Quality Initiative was used to assess all patients undergoing TCAR. Outcomes were compared between dialysis-dependent patients and those who were not. Patients with asymptomatic and symptomatic carotid stenosis were assessed separately. Primary outcomes included perioperative mortality, stroke, and transient ischemic attack (TIA). Secondary outcomes included myocardial infarction, overall cardiac complications, surgical site infection, length of stay, access site complications, cranial nerve injury, and hemodynamic instability. Cardiac complication included myocardial infarction, congestive heart failure and/or dysrhythmias. Univariate and multivariable analysis using multivariable logistic regression and cox regression models were used. A total of 20,927 patients undergoing TCAR were identified from 2016 to 2021. Among patients with asymptomatic carotid stenosis 12,275 (98.6%) were not on dialysis and 173 patients (1.4%) were on dialysis. Among patients with symptomatic carotid stenosis 8348 (98.5%) were not on dialysis, and 128 patients (1.5%) were on dialysis. Among asymptomatic and symptomatic patients, dialysis was not associated with an increased risk of perioperative stroke or TIA (Table). Asymptomatic dialysis-dependent patients had increased risk of perioperative mortality (0.7% vs 4.6%; P < .001), myocardial infarction (0.5% vs 2.3%; P = .002), and cardiac complications (1.9% vs 4.6%; P = .011). All dialysis patients had increased risks of prolonged length of stay. After adjustment, asymptomatic patients remained at increased odds of perioperative mortality (odd ratio [OR], 5.8; 95% confidence interval [CI], 2.2-15.0), stroke/mortality (OR, 2.9; 95% CI, 1.2-6.8), myocardial infarction (OR, 3.3; 95% CI, 1.1-9.2), and overall cardiac complications (OR, 2.2; 95% CI, 1.1-4.6). Perioperative revascularization outcomes among dialysis-dependent patients undergoing TCAR for carotid artery stenosis demonstrate acceptable stroke and TIA, when compared with nondialysis patients. Similar to previous studies studying carotid endarterectomy and carotid artery stenting, dialysis dependence is associated with increased risk of myocardial infarction and perioperative mortality following TCAR. Thus, carotid revascularization should be used selectively in asymptomatic dialysis-dependent patients.TablePerioperative outcomesAsymptomatic (n = 12,448)Symptomatic (n = 8476)No dialysis (n = 12,275, 98.6%)Dialysis (n = 173, 1.4%)P valueNo dialysis (n = 8,348, 98.5%)Dialysis (n = 128, 1.5%)P valuePerioperative mortality650.7%54.6%<.001891.5%22.5%.495Stroke/perioperative mortality1671.9%65.6%.0062334.0%44.9%.658Stroke1130.9%21.2%.7411712.0%21.6%.699TIA500.4%10.6%.722660.8%21.6%.333MI660.5%42.3%.002490.6%00.0%.381Cardiac complication2341.9%84.6%.0111922.3%43.1%.564Surgical site infection30.0%00.0%.83830.0%00.0%.831LOS >2 days146612%4224%<.001308937%6551%.001Access site complications3342.7%84.6%.1302372.8%00.0%.053Cranial nerve injury230.2%00.0%.569290.4%00.0%.496Hemodynamic instability (requiring IV medications).099.064 Hypotension203857%2847%130454%2341% Hypertension151643%3253%112646%3359%IV, intravenous; LOS, length of stay; MI, myocardial infarction; TIA, transient ischemic attack.Neurological events include stroke or TIA; cardiac complications include MI, congestive heart failure, and dysrhythmia. Boldface entries indicate statistical significance. Open table in a new tab