Management of carotid disease in the end-stage renal disease patient

Chronic kidney disease (CKD) has been increasing in incidence as a result of the growing prevalence of diabetes and other risk factors for cardiovascular disease. This study highlights reports related to management of carotid disease in patients with CKD, with a special emphasis on end-stage renal disease (ESRD). Several earlier studies found that patients with CKD are more likely to die from cardiovascular causes than progress to ESRD requiring dialysis. Data derived from the US Renal Data System showed that the 30-day stroke/death rate was 10% after carotid endarterectomy and 11% after carotid artery stenting in patients on dialysis, with a median postoperative survival of 2.5 years. However, these data were representative of a patient cohort from 2005 to 2008. In the past 2 decades, significant life expectancy gains have been noted for patients with ESRD. Recent studies reported adjusted mortality has decreased by 20% in patients on hemodialysis and 29% in patients who underwent transplantation. In addition, recent studies have found that among patients with CKD, carotid endarterectomy and transcarotid artery revascularization had stroke/death rates of <2% for asymptomatic patients and <3% for symptomatic patients. Based on studies published to date, the risk of carotid intervention, whether carotid endarterectomy or stenting, specifically transcarotid artery revascularization, can be justified for carefully selected symptomatic patients with severe CKD with acceptable operative risk and good long-term life expectancy. However, patients with asymptomatic carotid disease and severe CKD, specifically ESRD, should be offered best optimal medical therapy unless life expectancy exceeds what has been recommended by recent Society for Vascular Surgery carotid guidelines.