title: Perioperative and Long-term Outcomes After Carotid Endarterectomy in Hemodialysis Patients.
abstract: Early landmark trials excluding dialysis patients showed carotid endarterectomy (CEA) decreased stroke risk compared with medical management. Dialysis dependence has been associated with poor outcomes after CEA in small studies, but, to our knowledge, there are no large studies evaluating outcomes of CEA in this patient group.
  
  
  
  To delineate perioperative and long-term outcomes after CEA in dialysis-dependent patients in a large national database.
  
  
  
  A retrospective review of all patients who underwent CEA in the US Renal Disease System-Medicare-matched database between January 1, 2006, and December 31, 2011, was performed in June 2015. The median follow-up time was 2.5 years. Logistic and Cox regression analyses were used to evaluate perioperative and long-term outcomes.
  
  
  
  The primary outcomes of interest were perioperative stroke, myocardial infarction and mortality, and long-term stroke and mortality.
  
  
  
  A total of 5142 patients were studied; 83% of whom were asymptomatic. The mean (SD) age was 68.9 (9.6) years for asymptomatic patients and 70.0 (9.1) years for symptomatic patients. The 30-day stroke rate, myocardial infarction, and mortality for the asymptomatic and symptomatic groups were 2.7% vs 5.2% (P = .001), 4.6% vs 5.0% (P = .69), and 2.6% vs 2.9% (P = .61), respectively. Predictors of perioperative stroke were symptomatic status (odds ratio [OR], 2.01; 95% CI, 1.18-3.42; P = .01), black race (OR, 2.30; 95% CI, 1.24-4.25; P = .008), and Hispanic ethnicity (OR, 2.28; 95% CI, 1.17-4.42; P = .02). Freedom from stroke and overall survival were lower in symptomatic compared with asymptomatic patients at 1, 2, 3, 4, and 5 years (in asymptomatic vs symptomatic patients, freedom from stroke rates were 92% vs 87% at 1 year, 88% vs 83% at 2 years, 84% vs 78% at 3 years, 80% vs 73% at 4 years, and 79% vs 69% at 5 years, respectively, and overall survival rates were 78% vs 73% at 1 year, 60% vs 57% at 2 years, 46% vs 42% at 3 years, 37% vs 32% at 4 years, and 33% vs 29% at 5 years; P < .05). Predictors of long-term stroke were preoperative symptoms (hazard ratio, 1.67; 95% CI, 1.24-2.24; P < .001), female sex (hazard ratio, 1.34; 95% CI, 1.03-1.73; P = .04), and inability to ambulate (hazard ratio, 1.81; 95% CI, 1.25-2.62; P = .002). Predictors of long-term mortality were increasing age (OR, 1.02; 95% CI, 1.01-1.03; P < .01), active smoking (OR, 1.22; 95% CI, 1.00-1.48; P = .045), history of congestive heart failure (OR, 1.25; 95% CI, 1.12-1.39; P < .001), and chronic obstructive pulmonary disease (OR, 1.26; 95% CI, 1.09-1.45; P = .002).
  
  
  
  To our knowledge, this is the largest study to date of dialysis patients who have undergone CEA. We have shown that the risks of CEA in asymptomatic patients is high and may outweigh the benefits. The risk of CEA in symptomatic patients is also high, and it should only be offered to a small carefully selected cohort of symptomatic patients.
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Michol
authors.initials: M
authors.lastname: Cooper
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Isibor J
authors.initials: IJ
authors.lastname: Arhuidese
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Tammam
authors.initials: T
authors.lastname: Obeid
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Hicks
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Joseph
authors.initials: J
authors.lastname: Canner
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
mesh_terms: D000367:Age Factors; D000368:Aged; D058070:Asymptomatic Diseases / Q000453:epidemiology* / Q000401:mortality; D016208:Databases, Factual; D016894:Endarterectomy, Carotid / Q000706:statistics & numerical data*; D005260:Female; D006333:Heart Failure / Q000453:epidemiology; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D051346:Mobility Limitation; D009203:Myocardial Infarction / Q000453:epidemiology* / Q000208:ethnology / Q000401:mortality / Q000517:prevention & control; D011184:Postoperative Period; D029424:Pulmonary Disease, Chronic Obstructive / Q000453:epidemiology; D006435:Renal Dialysis; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors; D012907:Smoking / Q000453:epidemiology; D020521:Stroke / Q000453:epidemiology* / Q000208:ethnology / Q000401:mortality / Q000517:prevention & control; D015996:Survival Rate; D013997:Time Factors; D014481:United States / Q000453:epidemiology