1
|
Etkin Y, Iyeke L, Yu G, Ahmed I, Matera P, Aminov J, Kokkosis A, Hastings L, Garg K, Rockman C. Sex disparities in outcomes after carotid artery interventions: A systematic review. Semin Vasc Surg 2023; 36:476-486. [PMID: 38030321 DOI: 10.1053/j.semvascsurg.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/13/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023]
Abstract
This systematic review aimed to identify sex-specific outcomes in men and women after carotid endarterectomy (CEA) and carotid artery stenting (CAS), including transfemoral and transcarotid. A search of literature published from January 2000 through December 2022 was conducted using key terms attributed to carotid interventions on PubMed. Studies comparing outcome metrics post intervention (ie, myocardial infarction [MI], cerebral vascular accident [CVA] or stroke, and long-term mortality) among male and female patients were reviewed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Overall, all studies reported low rates of perioperative complications. Among the studies that did not stratify outcomes by the preoperative symptom status, there were no significant sex differences in rates of perioperative strokes or MIs. Two studies, however, noted a higher rate of 30-day mortality in male patients undergoing CEA than in female patients. Analysis of asymptomatic patients undergoing CEA revealed no difference in perioperative MIs (female: 0% to 1.8% v male: 0.4% to 4.3%), similar rates of CVAs (female: 0.8% to 5% v male: 0.8% to 4.9%), and no significant differences in the long-term mortality outcomes. Alternatively, symptomatic patients undergoing CEA reported a higher rate of CVAs in female patients vs. male patients (7.7% v 6.2%) and showed a higher rate of death in female patients (1% v 0.7%). Among studies that did not stratify outcome by symptomatology, there was no difference in the 30-day outcomes between sexes for patients undergoing CAS. Asymptomatic patients undergoing CAS demonstrated similar incident rates across perioperative MIs (female: 0% to 5.9% v male: 0.28% to 3.3%), CVAs (female: 0.5% to 4.1% v male: 0.4% to 6.2%), and long-term mortality outcomes (female: 0% to 1.75% v male: 0.2% to 1.5%). Symptomatic patients undergoing CAS similarly reported higher incidences of perioperative MIs (female: 0.3% to 7.1% v male: 0% to 5.5%), CVAs (female: 0% to 9.9% v male: 0% to 7.6%), and long-term mortality outcomes (female: 0.6% to 7.1% v male: 0.5% to 8.2%). Sex-specific differences in outcomes after major vascular procedures are well recognized. Our review suggests that symptomatic female patients have a higher incidence of neurologic and cardiac events after carotid interventions, but that asymptomatic patients do not.
Collapse
Affiliation(s)
- Yana Etkin
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042.
| | - Lisa Iyeke
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042
| | - Grace Yu
- Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, 1999 Marcus Avenue, Suite 106, Lake Success, NY, 11042
| | | | | | - Jonathan Aminov
- Division of Vascular and Endovascular Surgery, Stony Brook University Medical Center, Stony Brook, NY
| | - Angela Kokkosis
- Division of Vascular and Endovascular Surgery, Stony Brook University Medical Center, Stony Brook, NY
| | - Laurel Hastings
- Division of Vascular Surgery, Einstein Medical Center, Philadelphia, PA
| | - Karan Garg
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
| | - Caron Rockman
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
| |
Collapse
|
2
|
BIANCOFIORE B, DE BLASIS S, FALSO R, DOLFI L, PANELLA M, DI DOMENICO R, DORIGO W, PULLI R, PRATESI C. How to improve results in carotid surgery. Analysis of a 20-year case history of more than 7000 operations. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2023. [DOI: 10.23736/s1824-4777.22.01562-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
|
3
|
Nantakool S, Chuatrakoon B, Orrapin S, Leung R, Howard DPJ, Rerkasem A, Derraik JGB, Rerkasem K. Influences of age and gender on operative risks following carotid endarterectomy: A systematic review and meta-analysis. PLoS One 2023; 18:e0285540. [PMID: 37163559 PMCID: PMC10171679 DOI: 10.1371/journal.pone.0285540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/25/2023] [Indexed: 05/12/2023] Open
Abstract
OBJECTIVES This review aims to undertake a comprehensive review of the literature and investigate associations of age and gender on 30 days post carotid endarterectomy (CEA) and up to 5 years post CEA stroke, death, and combined stroke and death. DESIGN A systematic review and meta-analysis. METHODS Three main electronic databases including the Cochrane Library, MEDLINE, and Embase were searched from their inception to July 2022. Studies examining operative risks (i.e., stroke, death, and combined stroke and death following CEA) linked to age or gender were included. Two independent reviewers were responsible for study selection, quality assessment, and data extraction. Odds ratio (OR) and 95% confidence interval (CI) of all outcomes were calculated. RESULTS 44609 studies were retrieved from the search. There were 127 eligible studies (80 studies of age, 72 studies of gender, 25 studies of age and gender) for pooling in the meta-analysis. With regards to stroke and death risks within 30 days post CEA; patients aged ≥75 had higher death (OR 1.38; 95% CI 1.10-1.75) than patients aged <75. Patients aged ≥80 had higher stroke risk (OR 1.17; 95% CI 1.07-1.27) and death risk (OR 1.85; 95% CI 1.48-2.30) particular in asymptomatic patients (OR 2.4; 95% CI 1.56-3.81). Pooled effect estimates by gender, at 30 days post CEA, showed that female was associated with increased risk of stroke (OR 1.28; 95% CI 1.16-1.40), with more risk in asymptomatic female patients (OR 1.51; 95% CI 1.14-1.99). CONCLUSIONS This meta-analysis highlights that older people is associated with increased stroke risk, particularly asymptomatic octogenarians who had higher likelihood of death within 30 days post CEA. In addition, female especially those with asymptomatic carotid stenosis had greater likelihood of stroke within 30 days post CEA surgery.
Collapse
Affiliation(s)
- Sothida Nantakool
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
| | - Busaba Chuatrakoon
- Faculty of Associated Medical Sciences, Department of Physical Therapy, Chiang Mai University, Chiang Mai, Thailand
| | - Saritphat Orrapin
- Faculty of Medicine, Department of Surgery, Division of Vascular Surgery, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
| | - Rachel Leung
- Nuffield Department of Clinical Neurosciences, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Dominic P J Howard
- Nuffield Department of Clinical Neurosciences, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Amaraporn Rerkasem
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
| | - José G B Derraik
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Faculty of Medical and Health Sciences, Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Kittipan Rerkasem
- Research Institute for Health Sciences, Environmental-Occupational Health Sciences and Non Communicable Diseases Research Group (EOHS and NCD Research Group), Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Department of Surgery, Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Clinical Surgical Research Center, Chiang Mai University, Chiang Mai, Thailand
| |
Collapse
|
4
|
Li B, Eisenberg N, Howe KL, Forbes TL, Roche-Nagle G. The impact of sex on outcomes following carotid endarterectomy. Ann Vasc Surg 2022; 88:210-217. [PMID: 36029946 DOI: 10.1016/j.avsg.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Previous studies have demonstrated significant sex differences in vascular surgery outcomes. We assessed stroke or death rates following carotid endarterectomy (CEA) in women vs. men. METHODS The Vascular Quality Initiative (VQI) was used to identify all patients who underwent CEA between 2010-2019. Demographic, clinical, and procedural characteristics were recorded and differences between women vs. men were assessed using independent t-test and chi-square test. The primary outcomes were 30-day and 1-year stroke or death. Associations between sex and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis. RESULTS 52,137 women and 79,974 men underwent CEA in VQI sites during the study period. Women were younger (70.3 vs. 70.5 years, p < 0.001) and more likely to have hypertension (89.2% vs. 88.9%, p < 0.05) and diabetes (36.2% vs. 35.8%, p < 0.001), but less likely to be diagnosed with coronary artery disease (23.2% vs. 31.0%, p < 0.001). A greater proportion of men were receiving cardiovascular risk reduction medications and had symptomatic carotid stenosis (28.5% vs. 26.7%, p < 0.001). Women had shorter procedure times (113 vs. 122 minutes, p < 0.001) and were less likely to receive electroencephalography neuromonitoring (27.9% vs. 28.8%, p < 0.001), drain (35.9% vs. 37.3%, p < 0.001), and protamine (67.4% vs. 68.0%, p < 0.01). Stroke or death at 30 days (1.9% vs. 1.8%, p = 0.60) and 1 year (HR 0.98 [95% CI 0.94 - 1.01], p = 0.20) were similar between groups, which persisted in asymptomatic patients (HR 0.97 [95% CI 0.93 - 1.01], p = 0.17) and symptomatic patients (HR 0.99 [95% CI 0.93 - 1.05], p = 0.71). The similarities in 1-year stroke or death rates existed in both the US (HR 0.96 [95% CI 0.92 - 1.01], p = 0.09) and Canada (HR 1.21 [95% CI 0.47 - 3.11], p = 0.70). CONCLUSIONS Despite sex differences in clinical and procedural characteristics, women and men have similar 30-day and 1-year outcomes following carotid endarterectomy.
Collapse
Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn L Howe
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
5
|
Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
|
6
|
Cui CL, Zarrintan S, Marmor RA, Nichols J, Cajas-Monson L, Malas M. Performance of Carotid Revascularization Procedures as Modified by Sex. Ann Vasc Surg 2021; 81:171-182. [PMID: 34752853 DOI: 10.1016/j.avsg.2021.08.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current recommendations on carotid revascularization postulate that women have both increased perioperative risks, such as stroke and death, as well as reduced benefit from intervention. These recommendations do not include data on transcarotid artery revascularization (TCAR). This study strives to compare safety and benefits of TCAR, TFCAS (Transfemoral Carotid Artery Stenting), and CEA (Carotid Endarterectomy) with regard to patient sex. METHODS We performed retrospective analysis of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and stenting registries, as well as TCAR Surveillance Project data. We compared outcomes after TCAR, TFCAS, and CEA based on sex. The primary outcome was the rate of in-hospital stroke or death. Secondary outcomes included in-hospital stroke, death, transient ischemic attack (TIA), myocardial infarction (MI), stroke/death/MI, stroke/TIA, and recurrent ipsilateral stroke and/or death at 1-year of follow-up. RESULTS A total of 75,538 patients were included, of which 28,960 (38.3%) were female and 46,578 (61.7%) were male. TFCAS females had more than 2 times higher odds of stroke/death (OR:2.85, 95%CI: 2.21-3.67, P < 0.001) and stroke/death/MI (OR:2.23, 95%CI:1.75-2.83, P < 0.001) when compared to CEA females. Odds of TIA were also higher in both TFCAS females (OR:2.01, 95%CI:1.19-3.42, P = 0.010) and TCAR females (OR:1.91, 95%CI:1.09-3.35, P = .023) when compared to CEA females. However, only TFCAS females experienced increased odds of stroke/TIA (OR:1.96, 95%CI:1.45-2.65, P < 0.001) when compared to CEA females. TFCAS males had almost twice the odds of stroke/death (OR:1.74, 95%CI:1.39-2.16, P < 0.001) and 44% higher odds of stroke/death/MI (OR:1.44, 95%CI:1.19-1.75, P < 0.001), and more than 3-times increased odds of death (OR:3.45, 95%CI:2.53-4.71, P < 0.001) when compared to CEA males. Odds of in-hospital stroke were comparable between TFCAS and CEA after adjusting for covariates. TCAR males have half the odds of MI when compared to CEA males (OR:0.52, 95%CI:0.34-0.80, P = 0.003). At 1-year TCAR had comparable risk of stroke/death while TFCAS had increased risk of stroke/death when compared to CEA among both males and females. CONCLUSION TCAR performed similarly to CEA in both sexes regardless of symptomatic status. Stroke/death and stroke/death/MI rates were similar in symptomatic and asymptomatic males and females treated by CEA or TCAR. The 1-year outcomes of TCAR were also comparable to CEA in both sexes. It seems that TCAR may be a safe alternative to CEA particularly in women when surgical risk prohibits CEA and while TFCAS is associated with substantial adverse outcomes.
Collapse
|
7
|
Djedović M, Imširović B, Djedović S, Hadžimehmedagić A, Vukas H, Rovčanin B, Kamenjašević I. Carotid Endarterectomy in Women versus Man: Patient Characteristics and Perioperative Complication (<30 Day). Open Access Maced J Med Sci 2018; 6:463-466. [PMID: 29610601 PMCID: PMC5874366 DOI: 10.3889/oamjms.2018.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/02/2018] [Accepted: 02/07/2018] [Indexed: 11/05/2022] Open
Abstract
AIM Compare the basic characteristics of patients and to examine the existence of higher rates of perioperative complications (0 - 30 days) in women versus men after carotid endarterectomy (CEA). METHODS This is a retrospective-prospective study included 270 patients with significant stenosis of carotid in whom CEA was performed, during the period from 2012 to 2017. Patients they were divided: group 1 - 100 female patients, group 2 - 170 male patients. RESULTS No statistically significant age difference was observed between the two groups, group 1 - 66.01 years (SD 8.42, 46 to 86 years), group 2 - 66.46 years (SD 8.03, 47 to 85 years) (p = 0.659). Risk factors represent a greater prevalence in group 2, but the observed difference is not statistically significant. The average duration of surgery and the time of carotid artery clamping time were longer in group 1: (p = 0.002; p = 0.005). The number of classic endarterectomy with the patch was higher in women (41 (41%) versus 31 (18. 2%), p = 0.005), while the number of bilateral CEAs was not statistically significant. CONCLUSION The results of this study of this study did not indicate a greater presence of perioperative complications (< 30 days) in women versus male patients after CEA.
Collapse
Affiliation(s)
- Muhamed Djedović
- University Clinical Centre of Sarajevo - Clinic of Cardiovascular Surgery, Sarajevo, Bosnia and Herzegovina
| | - Bilal Imširović
- General Hospital „Prim. Dr. Abdulah Nakaš” - Radiology, Sarajevo, Bosnia and Herzegovina
| | | | - Amel Hadžimehmedagić
- University Clinical Centre of Sarajevo - Clinic for Cardiovascular Surgery, Sarajevo, Bosnia and Herzegovina
| | - Haris Vukas
- University Clinical Centre of Sarajevo - Clinic for Cardiovascular Surgery, Sarajevo, Bosnia and Herzegovina
| | | | | |
Collapse
|
8
|
Dorigo W, Fargion A, Giacomelli E, Bassoli G, Pulli R, Pratesi G, Piffaretti G, Pratesi C. A Matched Case-Control Study on Early and Late Results of Carotid Endarterectomy Performed in Young Patients. World J Surg 2017; 42:263-271. [PMID: 28733710 DOI: 10.1007/s00268-017-4133-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim of the study was to describe the perioperative and long-term results of carotid endarterectomy (CEA) in patients aged 60 or less and compare them to patients of more advanced age in a retrospective single-centre case-control study. METHODS From January 1996 to December 2014, 5893 consecutive CEAs were performed in our institution. Data concerning these interventions were prospectively inserted in a dedicated database. A retrospective analysis of that database was performed and 457 interventions performed in patients aged 60 or less were found (group 1). The control group was represented by 457 interventions selected from the remaining 5436 by a one-to-one coarsened exact matching on the basis of all the baseline demographic and clinical covariates significantly different in the two groups (group 2). The two groups were compared in terms of intraoperative technical features and perioperative (<30 days) results of interventions (transient ischaemic attack-TIA, stroke and death rates) with χ 2 test. Follow-up data were analysed by life-table analysis (Kaplan-Meier test) in terms of survival, stroke-free and neurological symptom-free survival, freedom from severe restenosis and occlusion and freedom from reintervention, and the results in the two groups were compared by means of log rank test. RESULTS There were no differences between the two groups in terms of clinical presentation and of degree of carotid stenosis on operated side. Anaesthesiological and surgical details were also similar between the two groups. Thirty-day stroke and death rate was 0.6% in both groups (p = 0.9). Follow-up was available for 877 patients (96% of the study group) with a mean duration of 50 months. Estimated 10-year survival rates were 85% in group 1 (SE 0.03) and 76% in group 2 (SE 0.04, p = 0.003, log rank 8.9). At the same time interval, stroke-free survival was also significantly better in group 1 (85%, SE 0.035) than in group 2 (72.5%, SE 0.03; p = 0.002, log rank 10.1). The corresponding figures in terms of any neurological symptom-free survival were 82.8% in group 1 (SE 0.04) and 70.3% in group 2 (SE 0.04, p = 0.002, log rank 9.7). Estimated freedom from severe restenosis and occlusion was 76.5% in group 1 (SE 0.04) and 88.5% in group 2 (SE 0.035, p = 0.001, log rank 11.9). Disease recurrence was symptomatic in six cases, three in each group. Estimated freedom from reintervention rates at 10 years was 87% in group 1 (SE 0.035) and 91.5% in group 2 (SE 0.03; p = 0.2, log rank 1.1). CONCLUSIONS CEA in patents aged 60 or less is safe and provides significantly better long-term results than those obtained in patients over 60 in terms of survival and stroke-free survival. Younger patients appear to have higher rates of recurrent carotid stenosis compared to the older cohort; however, these rarely require a secondary intervention.
Collapse
Affiliation(s)
- Walter Dorigo
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Largo Brambilla 3, 50134, Florence, Italy.
| | - Aaron Fargion
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Largo Brambilla 3, 50134, Florence, Italy
| | - Elena Giacomelli
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Largo Brambilla 3, 50134, Florence, Italy
| | - Giulia Bassoli
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Largo Brambilla 3, 50134, Florence, Italy
| | - Raffaele Pulli
- Department of Vascular Surgery, University of Bari, Bari, Italy
| | - Giovanni Pratesi
- Department of Vascular Surgery, University of Rome Tor Vergata, Rome, Italy
| | | | - Carlo Pratesi
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Largo Brambilla 3, 50134, Florence, Italy
| |
Collapse
|
9
|
La mujer y la enfermedad vascular: características específicas. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2015.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
10
|
Davidovic L, Koncar I, Dragas M, Markovic M, Ilic N, Mutavdzic P, Banzic I, Ristanovic N. Female and Obese Patients Might Have Higher Risk from Surgical Repair of Asymptomatic Carotid Artery Stenosis. Ann Vasc Surg 2015; 29:1286-92. [DOI: 10.1016/j.avsg.2015.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 02/18/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
|
11
|
Luebke T, Brunkwall J. Meta- analysis and meta-regression analysis of the associations between sex and the operative outcomes of carotid endarterectomy. BMC Cardiovasc Disord 2015; 15:32. [PMID: 25956903 PMCID: PMC4432947 DOI: 10.1186/s12872-015-0029-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/21/2015] [Indexed: 12/26/2022] Open
Abstract
Background Subgroup analyses from randomized controlled trials (RCT) of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis suggest less benefit in women compared to men, due partly to higher age-independent peri-operative risk. However, a meta-analysis of case series and databases focussing on CEA-related gender differences has never been investigated. Methods A systematic review of all available publications (including case series, databases and RCTs) reporting data on the association between sex and procedural risk of stroke and/or death following CEA from 1980 to 2015 was investigated. Pooled Peto odds ratios of the procedural risk of stroke and/or death were obtained by Mantel-Haenszel random-effects meta-analysis. The I2 statistic was used as a measure of heterogeneity. Potential publication bias was assessed with the Egger test and represented graphically with Begg funnel plots of the natural log of the OR versus its standard error. Additional sensitivity analyses were undertaken to evaluate the potential effect of key assumptions and study-level factors on the overall results. Meta-regression models were formed to explore potential heterogeneity as a result of potential risk factors or confounders on outcomes. A tria sequential analysis (TSA) was performed with the aim to maintain an over- all 5 % risk of type I error, being the standard in most meta- analyses and systematic reviews. Results 58 articles reported combined stroke and mortality rates within 30 days of treatment. In the unselected overall meta-analysis, the incidence of stroke and death in the male and female groups differed significantly (Peto OR, 1,162; 95 % CI, 1.067-1.266; P = .001), revealing a worse outcome for female patients. Moderate heterogeneity among the studies was identified (I2 = 36 %), and the possibility of publication bias was low (P = .03). In sensitivity analyses the meta-analysis of case series with gender aspects as a secondary outcome showed a significantly increased risk for 30-day stroke and death in women compared to men (Peto OR, 1.390; 95 % CI, 1.148-1.684; P = .001), In contrast, meta-analysis of databases (Peto OR, 1.025; 95 % CI, 0.958-1.097; P = .474) and case series with gender related outcomes as a primary aim (Peto OR, 1.202; 95 % CI, 0.925-1.561; P = .168) demonstrated no increase in operative risk of stroke and death in women compared to men. Conclusions Metanalyses of case series and databases dealing with CEA reveal inconsistent results regarding gender differences related to CEA-procedure and should not be transferred into clinical practice.
Collapse
Affiliation(s)
- Thomas Luebke
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
| |
Collapse
|
12
|
Hedayati N, Humphries MD, Zhou W. Gender and Outcomes of Carotid Artery Interventions. Vasc Endovascular Surg 2013; 48:99-105. [DOI: 10.1177/1538574413510978] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The benefits of carotid artery revascularization in women have been debated since the publication of large randomized clinical trials comparing carotid endarterectomy (CEA) to medical therapy. Institutional series have historically had an underrepresentation of women and/or have lacked power for adequate analysis. Recent evidence from large databases reveals possible gender-based differences in outcomes of carotid artery stenting versus CEA. In this review, we evaluated clinical articles from 1991 to 2012, using Pubmed and Web of Science, which addressed gender and outcomes of carotid artery revascularization procedures. Our goal was to determine whether gender is associated with adverse outcomes following carotid artery interventions in patients with carotid artery disease.
Collapse
Affiliation(s)
- Nasim Hedayati
- Division of Vascular and Endovascular Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Misty D. Humphries
- Division of Vascular and Endovascular Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Wei Zhou
- Division of Vascular and Endovascular Surgery, Stanford University, Palo Alto, CA, USA
| |
Collapse
|
13
|
Guzman RP, Weighell W, Guzman C, Rodriguez-Leyva D. Female sex does not influence 30-day stroke and mortality rates after carotid endarterectomy. Ann Vasc Surg 2013; 28:245-52. [PMID: 24011811 DOI: 10.1016/j.avsg.2013.02.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 10/27/2012] [Accepted: 02/06/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sex-based differences in outcomes for the treatment of carotid arterial disease remains a controversial topic. The main objective of this study was to determine if gender differences influence 30-day stroke and mortality rates after carotid endarterectomy (CEA) in a large series of patients. METHODS This is a retrospective study of all patients undergoing endarterectomy performed by a single surgeon between January 1, 1993 and December 15, 2010. The analysis included data from 1,046 CEAs (683 men and 363 women). RESULTS There were no differences found in 30-day stroke, death, or combined stroke and death rates between women and men. The 30-day stroke rate was 1.6% for women and 1.8% for men (P = 0.98), with no significant differences between asymptomatic patients (1.7% for women vs. 1.2% for men; P = 0.70) or symptomatic patients (1.6% for women vs. 2.1% for men; P = 0.74). The 30-day mortality rate was 0.8% for women and 0.9% for men (P = 0.85) with no significant differences between asymptomatic patients (0.8% for women vs. 1.2% for men; P = 0.77) and symptomatic patients (0.8% for women vs. 0.7% for men; P = 0.84). There was a similar low risk for the combined outcome of stroke and death (1.9% for women vs. 2.2% for men; P = 0.92), with no differences between asymptomatic patients (1.7% for women vs. 1.6% for men; P = 0.89) or symptomatic patients (2.1% for women vs. 2.5% for men; P = 0.84). CONCLUSIONS Female sex does not influence 30-day stroke and mortality rates after CEA, regardless of preoperative symptom status.
Collapse
Affiliation(s)
- Randolph P Guzman
- Section of Vascular Surgery, Department of Surgery, Saint Boniface Hospital, Winnipeg, Manitoba, Canada; I. H. Asper Clinical Research Institute, Saint Boniface Research Centre, Winnipeg, Manitoba, Canada.
| | - Wendy Weighell
- Section of Vascular Surgery, Department of Surgery, Saint Boniface Hospital, Winnipeg, Manitoba, Canada; I. H. Asper Clinical Research Institute, Saint Boniface Research Centre, Winnipeg, Manitoba, Canada
| | - Catherine Guzman
- Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | |
Collapse
|
14
|
Pulli R, Dorigo W, Pratesi G, Fargion A, Angiletta D, Pratesi C. Gender-related outcomes in the endovascular treatment of infrainguinal arterial obstructive disease. J Vasc Surg 2012; 55:105-12. [DOI: 10.1016/j.jvs.2011.07.050] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 07/05/2011] [Accepted: 07/08/2011] [Indexed: 11/27/2022]
|
15
|
Grootenboer N, Hunink M, Hoeks S, Hendriks J, van Sambeek M, Poldermans D. The Impact of Gender on Prognosis After Non-cardiac Vascular Surgery. Eur J Vasc Endovasc Surg 2011; 42:510-6. [DOI: 10.1016/j.ejvs.2011.06.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 06/15/2011] [Indexed: 11/30/2022]
|
16
|
Outcome of carotid artery interventions among female patients, 2004 to 2005. J Vasc Surg 2011; 53:1457-64. [DOI: 10.1016/j.jvs.2011.02.029] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 02/14/2011] [Accepted: 02/14/2011] [Indexed: 11/22/2022]
|
17
|
Halliday A. Invited commentary: outcome of carotid artery interventions among female patients, 2004 to 2005. J Vasc Surg 2011; 53:1464-5. [PMID: 21609794 DOI: 10.1016/j.jvs.2011.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 02/14/2011] [Accepted: 02/17/2011] [Indexed: 11/25/2022]
|
18
|
Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, Pan H, Peto R, Potter J, Rahimi K, Rau A, Robertson S, Streifler J, Thomas D. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet 2010; 376:1074-84. [PMID: 20870099 PMCID: PMC2956884 DOI: 10.1016/s0140-6736(10)61197-x] [Citation(s) in RCA: 602] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND If carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA. METHODS Between 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3-2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6-11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392. FINDINGS 1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7% versus 4·8% at 1 year (and 92·1%vs 16·5% at 5 years). Perioperative risk of stroke or death within 30 days was 3·0% (95% CI 2·4-3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1% versus 10·0% at 5 years (gain 5·9%, 95% CI 4·0-7·8) and 10·8% versus 16·9% at 10 years (gain 6·1%, 2·7-9·4); ratio of stroke incidence rates 0·54, 95% CI 0·43-0·68, p<0·0001. 62 versus 104 had a disabling or fatal stroke, and 37 versus 84 others had a non-disabling stroke. Combining perioperative events and strokes, net risks were 6·9% versus 10·9% at 5 years (gain 4·1%, 2·0-6·2) and 13·4% versus 17·9% at 10 years (gain 4·6%, 1·2-7·9). Medication was similar in both groups; throughout the study, most were on antithrombotic and antihypertensive therapy. Net benefits were significant both for those on lipid-lowering therapy and for those not, and both for men and for women up to 75 years of age at entry (although not for older patients). INTERPRETATION Successful CEA for asymptomatic patients younger than 75 years of age reduces 10-year stroke risks. Half this reduction is in disabling or fatal strokes. Net benefit in future patients will depend on their risks from unoperated carotid lesions (which will be reduced by medication), on future surgical risks (which might differ from those in trials), and on whether life expectancy exceeds 10 years. FUNDING UK Medical Research Council, BUPA Foundation, Stroke Association.
Collapse
Affiliation(s)
- Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
|