Long Term Mortality Rate in Patients Treated with Carotid Endarterectomy
Katarina Wadén1, Rebecka Hultgren2, Maria Ioanna Kotopouli3
1Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.
Insights
Carotid endarterectomy (CEA) patients have similar long-term mortality whether symptomatic or not. However, men experienced worse outcomes than women, indicating a need for sex-specific secondary prevention strategies after CEA.
Area of Science:
- Vascular Surgery
- Stroke Prevention
- Public Health
Background:
- Carotid endarterectomy (CEA) is a key intervention for stroke prevention in patients with carotid stenosis.
- Long-term mortality data in CEA patients are limited despite advancements in medical and surgical care.
- Understanding long-term outcomes and identifying risk factors are crucial for optimizing patient management.
Purpose of the Study:
- To evaluate the long-term all-cause mortality rate in patients who underwent CEA.
- To compare mortality rates between asymptomatic and symptomatic patients.
- To investigate sex differences in long-term mortality and identify factors influencing outcomes.
Main Methods:
- A two-center, non-randomized observational study of 1,033 CEA patients (1998-2017).
- Data on mortality and comorbidities were collected from national registries and medical records.
- Cox regression analysis was used to assess associations between clinical characteristics and outcomes, including standardized mortality ratio (SMR).
Main Results:
- Overall long-term mortality was similar for asymptomatic and symptomatic patients (34.2% vs. 33.7%).
- Women had a lower crude mortality rate than men in the first 10 years post-CEA.
- Increased SMR was observed in the first five years post-surgery, particularly in women and patients under 80.
Conclusions:
- Long-term mortality after CEA is comparable for symptomatic and asymptomatic patients.
- Significant sex differences in outcomes exist, with men facing worse prognosis.
- Tailored secondary prevention strategies are essential to mitigate long-term adverse effects in CEA patients.
Objective:
Carotid endarterectomy (CEA) is an effective surgical method for stroke prevention in selected patients with carotid stenosis. Few contemporary studies report on the long term mortality rate in CEA treated patients, despite continuous changes in medication, diagnostics, and patient selection. Here, the long term mortality rate is described in a well characterised cohort of asymptomatic and symptomatic CEA patients, sex differences evaluated, and mortality ratio compared with the general population.
Methods:
This was a two centre, non-randomised, observational study evaluating all cause, long term mortality in CEA patients from Stockholm, Sweden between 1998 and 2017. Death and comorbidities were extracted from national registries and medical records. Cox regression was adapted to analyse associations between clinical characteristics and outcome. Sex differences and standardised mortality ratio (SMR, age and sex matched) were studied.
Results:
A total of 1 033 patients were followed for 6.6 ± 4.8 years. Of those, 349 patients died during follow up where the overall mortality rate was similar in asymptomatic and symptomatic patients (34.2% vs. 33.7%, p = .89). Symptomatic disease did not influence the mortality risk (adjusted HR 1.14, 95% CI 0.81 - 1.62). Women had lower crude mortality rate than men in the first 10 years (20.8% vs. 27.6%, p = .019). In women, cardiac disease was associated with increased mortality (adjusted HR 3.55, 95% CI 2.18 - 5.79), while in men, lipid lowering medication was protective (adjusted HR 0.61, 95% CI 0.39 - 0.96). Within the first five years after surgery, SMR was increased for all patients (men 1.50, 95% CI 1.21 - 1.86; women 2.41, 95% CI 1.74 - 3.35), as well as in patients < 80 years (SMR 1.46, 95% CI 1.23 - 1.73).
Conclusion:
Symptomatic and asymptomatic carotid patients have similar long term mortality rates after CEA, but men had worse outcome than women. Sex, age, and time after surgery were shown to influence SMR. These results highlight the need for targeted secondary prevention, to alter the long term adverse effects in CEA patients.
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