Outcomes after carotid artery stenting in hemodialysis patients.
Patients who require hemodialysis are historically excluded from randomized studies of carotid artery stenting (CAS) due to perceived poor outcomes. Observational studies of outcomes after CAS in hemodialysis patients are mostly limited to small, single-institution series.



This study evaluated long-term outcomes after CAS in a large nationally representative cohort of hemodialysis patients.



We studied all patients who underwent CAS in the United States Renal Disease System database between January 2006 and December 2011. Patient outcomes were determined by matching with the Medicare database. Univariable and multivariable logistic and Cox regression were used to compare perioperative (stroke, death, myocardial infarction) and long-term (stroke, death) outcomes after CAS.



The cohort included 1109 patients who underwent CAS. Median follow-up was 2.5 years (interquartile range, 1.30-3.71; maximum, 4.97 years). Mean age was 67 (standard deviation, 9.9) years, and 61% of patients were male, 75% were white, and 83% were asymptomatic. Overall, 30-day perioperative stroke, myocardial infarction, and death rates were 5.5%, 5.5%, and 3.1%, respectively. Long-term freedom from stroke was 90% at 1 year, 85% at 2 years, and 76% at 4 years. Patient survival was 73% at 1 year and 29% at 4 years. Symptomatic status was the only significant predictor of stroke in a long-term period of 4 years (hazard ratio, 1.92; 95% confidence interval, 1.12-3.29; P < .05).



This study, which is the largest population-based study of outcomes after CAS in hemodialysis patients, demonstrates relatively poor long-term survival and prohibitive operative stroke and death risk. We recommend avoidance of CAS in asymptomatic dialysis patients and cautious consideration when planning CAS in symptomatic patients.
Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
Isibor J
IJ
Arhuidese
Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
Tammam
T
Obeid
Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
Caitlin W
CW
Hicks
Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
Kanhua
K
Yin
Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
Joseph
J
Canner
Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
Dorry
D
Segev
Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md. Electronic address: bmalas1@jhmi.edu.
Mahmoud B
MB
Malas
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D002340:Carotid Artery Diseases / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007674:Kidney Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000209:etiology; D018579:Patient Selection; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States