Perioperative Outcomes After Carotid Revascularization in Asian Patients Varies With Asian Procedure Density

Abstract

The nature of postoperative outcomes following carotid revascularization is understudied in Asian patients. We aimed to determine if there are disparities in disease severity and postoperative outcomes in Asian patients following carotid revascularization and whether this varies with procedure frequency in Asian patients. We analyzed the Society for Vascular Surgery Vascular Quality Initiative Carotid Endarterectomy and Carotid Artery Stenting datasets from 2003 to 2021. We divided regions into tertiles based on Asian procedure density. Propensity scores were used to match White and Asian patients based on age, sex, comorbidities, contralateral carotid occlusion, and procedure type. Logistic and Cox regressions were performed within the matched cohort. The primary outcome variable was in-hospital ipsilateral stroke/death/myocardial infarction and we also examined differences in disease severity, center and surgeon volume, and late outcomes. A total of 159,608 White and 1766 Asian patients underwent carotid revascularization and we identified 2704 patients in the matched cohort. On adjusted analysis, there was no difference in symptomatic disease rate between groups (35%). However, Asian patients more commonly presented with >80% ipsilateral stenosis (63% vs 52%; P < .001) and a moderate/severe preoperative Rankin score (7.6% vs 5.1%; P = .007), which did not vary with Asian procedure density. The rate of in-hospital stroke/death/myocardial infarction was higher in Asian patients (2.6% vs 1.3%; P = .012), and this disparity was more pronounced in the lowest tertile of Asian procedure density (4.3% vs 0.5%; P < .001). Logistic regression within the propensity-matched cohort demonstrated Asian race was associated with a decreased odds of care by highest volume centers and surgeons, which was largely consistent across tertiles of Asian procedure density (Table I). Asian race was associated with twofold greater odds of in-hospital stroke/death/myocardial infarction, which was driven by the lowest tertile regions of Asian procedure density. After clustering at surgeon and center level, the effect of Asian race was mitigated. Cox regression within the matched cohort demonstrated that Asian race was protective against late mortality, with no differences in 1-year stroke or reintervention-free survival (Table II). Asian patients are more likely to present with a greater degree of carotid stenosis, preoperative risk, and experience worse perioperative outcomes. The increased odds of perioperative stroke/death/myocardial infarction is driven by regions with low Asian procedure density and is also mediated by the volume of centers and surgeons with which Asian patients tend to undergo care. These results highlight the need to understand the social and cultural effects on outcomes disparities in Asian patients.Table ILogistical regression of outcomes in propensity-matched cohortAssociation With Asian RaceOR (95% CI; P)ORa (95% CI; P)In-hospital stroke/death/myocardial infarction2.1 (1.2-3.7; P = .014)1.4 (0.7-3.0; P = .354)Operation at highest volume centers0.2 (0.2-0.3; P < .001)--Operation with highest volume surgeons0.3 (0.3-0.4; P < .001)--CI, Confidence interval; OR, odds ratio.aLogistical regression with clustering at surgeon and center level. Open table in a new tab Table IICox regression of late outcomes in propensity-matched cohortAsian RaceHR (95% CI, P)Long-term mortality0.6 (0.4-0.9; P = .011)1-year stroke-free survival1.1 (0.3-3.9; P = .878)1-year reintervention-free survival5.0 (0.8-33.0; P = .091)HR, Hazard ratio; OR, odds ratio. Open table in a new tab