Female sex and outcomes of symptomatic carotid stenosis revascularization

Since stroke continues to be a major worldwide cause of death and disability, its prevention and treatment have become increasingly significant to public health. Up to 20% of all strokes are caused by carotid artery disease (CAD). Carotid revascularization techniques such as carotid endarterectomy (CEA) and carotid artery stenting (CAS) are established procedures aimed at reducing stroke risk. Recent studies, while confirming their effectiveness, suggest that women may experience different and sometimes less favorable post-operative outcomes compared to men. These differences stem from factors including anatomy, physiology, hormones, and socioeconomics. Current clinical guidelines rarely include gender-specific recommendations, as women have historically been underrepresented in clinical trials. However, the limited literature on risk assessment for women with CAD highlights significant differences. In this narrative review, we explore the impact of sex-related differences in CAD, outcomes of revascularization, and patterns of diagnosis and referral. We also highlight the gaps hindering personalized medical approaches. We examine the influence of anatomical and physiological variations on procedural risks, analyze hormonal effects on vascular wall physiology, and address metabolic differences between genders. Additionally, we discuss specific perioperative considerations for women and review current guidelines, identifying controversial issues arising from the lack of gender-based evidence. A key objective of this review is to emphasize the importance of research into personalized therapeutic strategies, aiming to improve the understanding of gender-specific influences and ultimately enhance outcomes for women undergoing carotid revascularization.