Poor Outcomes of Carotid Endarterectomy in Dialysis Patients

For patients on hemodialysis—particularly those with neurologic symptoms—the high risks of carotid endarterectomy (CEA) may outweigh the benefits, according to a study in JAMA Surgery.

The retrospective analysis included data on 5142 dialysis-dependent patients undergoing CEA from 2006 to 2011 drawn from the US Renal Data System. Perioperative and long-term outcomes were assessed at a median follow-up of 2.5 years.

Eighty-three percent of patients were asymptomatic, with no stroke or transient ischemic attack within the previous 6 months. Stroke occurred within 30 days after CEA in 2.7% of the asymptomatic group and 5.2% of the symptomatic group. The myocardial infarction rate was 4.6% versus 5.0%, respectively; mortality was 2.6% versus 2.9%, respectively. Factors associated with a higher perioperative stroke risk were symptomatic status (OR of 2.01), black race (OR of 2.30), and Hispanic ethnicity (OR of 2.28).

From 1 to 5 years, symptomatic patients had higher rates of stroke and death. Five-year overall survival was 33% in asymptomatic patients and 29% in symptomatic patients. Factors associated with higher long-term stroke risk were symptomatic status (HR of 1.67), women (HR of 1.34), and nonambulatory status (HR of 1.81). Risk factors for long-term mortality were older age (OR of 1.02), active smoking (OR of 1.22), history of congestive heart failure (OR of 1.25), and chronic obstructive pulmonary disease (OR of 1.26).

This large analysis suggests “relatively poor” perioperative and long-term outcomes of CEA in dialysis patients. The authors recommend “optimizing medical management and avoiding CEA” in symptomatic patients and considering CEA only in a “small and carefully selected” group of asymptomatic patients [Cooper M, et al. Perioperative and long-term outcomes after carotid endarterectomy in hemodialysis patients. JAMA Surg 2016, in press].