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Carotid Revascularization in Asymptomatic Patients after Renal Transplantation
Isibor Arhuidese1, Rebecca Craig-Schapiro1, Tammam Obeid1
1Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, MD.
Insights
Outcomes for carotid revascularization in renal transplant patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS) showed no significant differences in perioperative or long-term risks. However, complication rates were high, potentially outweighing benefits.
Area of Science:
- Cardiovascular Medicine
- Nephrology
- Vascular Surgery
Background:
- Chronic renal insufficiency increases risks after carotid revascularization.
- Renal transplantation improves survival but its impact on carotid revascularization outcomes is unknown.
Purpose of the Study:
- To evaluate periprocedural and long-term risks of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in renal transplant patients.
Main Methods:
- A cohort of US Renal Data System patients who underwent CEA or CAS (2006-2011) was studied.
- Medicare data linkage was used to determine outcomes.
- Propensity score matched logistic and Cox regression analyses assessed perioperative and long-term stroke, myocardial infarction (MI), and death.
Main Results:
- No significant differences in perioperative stroke, MI, or death rates were found between CEA (387 patients) and CAS (75 patients).
- Long-term stroke-free survival and overall patient survival showed no significant differences between CEA and CAS.
- Propensity score matched analysis revealed no difference in perioperative or long-term risks for CAS compared to CEA.
Conclusions:
- This study is the first to assess CEA and CAS outcomes in renal transplant recipients.
- Perioperative complication rates in this cohort exceed recommendations, suggesting benefits may be outweighed by risks.
- Reduced life expectancy and excess periprocedural morbidity warrant careful consideration for revascularization in these patients.
Background:
In multiple studies, chronic renal insufficiency has been associated with increased risk of periprocedural stroke, cardiac complications, and death following carotid revascularization. Renal transplantation has been shown to reduce cardiovascular risk and improve survival; outcomes after carotid revascularization in renal transplant patients however are unknown. In this study, we evaluate periprocedural and long-term risks after carotid endarterectomy (CEA) and carotid artery stenting (CAS) in a cohort of renal transplant patients.
Methods:
We studied all renal transplant patients in the United States Renal Data System who underwent CEA or CAS between January 2006 and December 2011. Patient outcomes were determined by linking with the Medicare database. Propensity score matched logistic and cox regression analyses were employed to evaluate perioperative stroke, myocardial infarction (MI), and death and long-term stroke and death.
Results:
Of the 462 revascularizations for asymptomatic carotid artery stenosis between 2006 and 2011, 387 (84%) were CEA and 75 (16%) were CAS. The 2 groups did not differ in age, gender, sex, race, or baseline medical characteristics. There was no significant difference in perioperative stroke, MI, or death rates in the CEA cohort (4.7%, 4.4%, and 1.3%, respectively) compared with the CAS cohort (5.3%, 2.7%, and 4.0%, respectively). Stroke-free survival for CEA versus CAS was 93% vs. 92% at 1 year, 90% vs. 87% at 2 years, 88% vs. 87% at 3 years, and 84% vs. 82% at 4 years (P = 0.81). Overall patient survival for CEA versus CAS was 89% vs. 88% at 1 year, 77% vs. 75% at 2 years, 66% for both at 3 years, and 53% vs. 48% at 4 years (P = 0.68). In propensity score matched Cox regression analysis, there was no difference in risk of perioperative stroke or MI or in long-term stroke or death for CAS compared with CEA.
Conclusions:
This is the first study to evaluate outcomes following CEA and CAS in renal transplant patients. The incidence of perioperative complications in this group is higher than the maximum recommended by the Society of Vascular Surgery, and the benefits of revascularization may be outweighed by the excess periprocedural morbidity and reduced life expectancy of these patients.
