Body mass index and outcome after revascularization for symptomatic carotid artery stenosis
Eline J Volkers1, Jacoba P Greving2, Jeroen Hendrikse2
1From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), Julius Center for Health Sciences and Primary Care (E.J.V., J.P.G., A.A.), and Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands; IVPE (J.-P.B.), Hopital Privé Paul D'Egine Champigny, France; Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland; Department of Brain Repair and Rehabilitation (L.H.B., M.M.B.), UCL Institute of Neurology, University College London, UK; Department of Neurology (T.G.B.), Mayo Clinic, Jacksonville, FL; Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Oxford University, UK; Department of Neurology (D.C., J.-L.M.), Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France; Department of Vascular and Endovascular Surgery/Vascular Center (H.-H.E.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Vascular Surgery (G.F.), Medical University of Innsbruck, Austria; London School for Hygiene and Tropical Medicine (J.G.); Nuffield Department of Surgical Sciences (A.H.), John Radcliffe Hospital, Oxford, UK; Department of Biostatistics (G.H.), UAB School of Public Health, Birmingham, AL; Clinic for Radiology and Neuroradiology (O.J.), UKSH Campus Kiel, Germany; Cardiovascular Associates of the Southeast (G.S.R.), Birmingham, AL; and Department of Neurology (P.A.R.), University of Heidelberg Medical School, Germany. E.J.Volkers@umcutrecht.nl.
Objective:
To determine whether the obesity paradox exists in patients who undergo carotid artery stenting (CAS) or carotid endarterectomy (CEA) for symptomatic carotid artery stenosis.
Methods:
We combined individual patient data from 2 randomized trials (Endarterectomy vs Angioplasty in Patients with Symptomatic Severe Carotid Stenosis and Stent-Protected Angioplasty vs Carotid Endarterectomy) and 3 centers in a third trial (International Carotid Stenting Study). Baseline body mass index (BMI) was available for 1,969 patients and classified into 4 groups: <20, 20-<25, 25-<30, and ≥30 kg/m2. Primary outcome was stroke or death, investigated separately for the periprocedural and postprocedural period (≤120 days/>120 days after randomization). This outcome was compared between different BMI strata in CAS and CEA patients separately, and in the total group. We performed intention-to-treat multivariable Cox regression analyses.
Results:
Median follow-up was 2.0 years. Stroke or death occurred in 159 patients in the periprocedural (cumulative risk 8.1%) and in 270 patients in the postprocedural period (rate 4.8/100 person-years). BMI did not affect periprocedural risk of stroke or death for patients assigned to CAS (ptrend = 0.39) or CEA (ptrend = 0.77) or for the total group (ptrend = 0.48). Within the total group, patients with BMI 25-<30 had lower postprocedural risk of stroke or death than patients with BMI 20-<25 (BMI 25-<30 vs BMI 20-<25; hazard ratio 0.72; 95% confidence interval 0.55-0.94).
Conclusions:
BMI is not associated with periprocedural risk of stroke or death; however, BMI 25-<30 is associated with lower postprocedural risk than BMI 20-<25. These observations were similar for CAS and CEA.
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