Sex-Based Outcomes After Carotid Artery Revascularization in Symptomatic Patients: A Multi-Center Cohort Study

Sex-based differences in outcomes after carotid revascularization remain poorly defined in symptomatic patients. We aimed to compare short and long-term outcomes between men and women with symptomatic carotid artery disease who underwent carotid revascularization across a ten-year period in three stroke centers.

A retrospective study was conducted on a consecutive series of cases between 2016 and 2026. Cases included patients presenting with stroke, transient ischemic attack (TIA), or amaurosis fugax attributable to ipsilateral carotid artery stenosis within six months prior carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), or transfemoral carotid artery stenting (TFCAS). Patients with prior neck radiation were excluded. Primary outcomes were stroke, TIA, myocardial infarction (MI), and death within 30 days. Secondary outcomes included long-term stroke, TIA, MI, death, restenosis, and reintervention. Both primary and secondary outcomes were analyzed individually and as a composite endpoint. To account for sex-based differences and vulnerable plaque feature burden, a 1:1 propensity score-matched (PSM) analysis was performed among patients with available magnetic resonance angiography with vessel wall imaging (MRA-VWI).

A total of 822 procedures were performed (men: 571, 69.5%; women: 251, 30.5%) with a mean age of 73.2 ± 9.2 years. Procedure distribution was similar between groups (CEA: 69.4% vs 70.9%; TCAR: 6.1% vs 5.6%; TFCAS: 24.5% vs 23.5%, p=0.89). Demographics and comorbidities were otherwise comparable between groups. Women had higher total cholesterol (185.9 ± 50.1 vs 158.1 ± 43.4 mg/dL, p<0.01), HDL (56.8 ± 18.1 vs 45.9 ± 15.2 mg/dL, p<0.01), and LDL (101.5 ± 45.4 vs 86.3 ± 38.0 mg/dL, p<0.01); however, the LDL/HDL ratio was not significant. Medication regimens were similar between groups, except estrogen use, which was exclusive to women (4.0%, p<0.01). Symptom presentation was comparable for stroke (49.0% vs 48.6%, p=0.91), TIA (32.0% vs 33.5%, p=0.69), and amaurosis fugax (22.1% vs 20.7%, p=0.67). At 30 days, the composite of stroke, TIA, MI, and death was similar (4.2% vs 4.0%, p=0.88), with no statistically significant differences in ipsilateral stroke (2.5% vs 1.6%, p=0.61), TIA (0.7% vs 1.6%, p=0.23), MI (0.5% vs 0.0%, p=0.25), or mortality (0.5% vs 1.2%, p=0.30). On long-term follow-up at 3.3 ± 2.6 years, the composite outcomes remained comparable (24.2% vs 24.3%, p=0.97), as were ipsilateral stroke (3.7% vs 5.2%, p=0.32), TIA (5.1% vs 4.0%, p=0.50), MI (2.6% vs 3.6%, p=0.45), mortality (17.5% vs 19.1%, p=0.58), restenosis (4.9% vs 7.2%, p=0.19), and reintervention rates (2.5% vs 4.8%, p=0.08). In the PSM cohort (men: 91, women: 91, N=182), the 30-day (3.3% vs 2.2%, p=1.00) and long-term (34.1% vs 31.9%, p=0.88) composite outcome of stroke, TIA, MI and death were similar. Restenosis (4.4% vs 7.7%, p=0.54), and reintervention (1.1% vs 6.6%, p=0.12) were also not statistically significantly different between groups.

No statistically significant sex-based differences were identified in 30-day or long-term outcomes after CEA, TCAR, or TFCAS across a ten-year period at three high-volume stroke centers. Furthermore, on propensity score matching of our highest risk patient population with vulnerable plaque features did not affect their short- and long-term outcomes.