Mechanisms of gender-related outcome differences after carotid endarterectomy

The influence of gender on 30-day adverse clinical outcomes in patients undergoing carotid surgery

BACKGROUND

We aimed to further evaluate sex differences of perioperative and 30-day complications after carotid surgery in patients with both asymptomatic and symptomatic carotid artery stenosis.

METHODS

This was a single-center prospective cohort study including 2013 consecutive patients, who were treated surgically due to extracranial carotid artery stenosis and prospectively followed. Patients who underwent carotid artery stenting and who were treated conservatively were excluded. The primary endpoints for this study were hospital stroke/transitory ischemic attack (TIA) and overall survival rates. Secondary outcomes included all other hospital adverse events, 30-day stroke/TIA, and 30-day mortality rates.

RESULTS

Hospital mortality was higher in female patients with symptomatic carotid stenosis (3% vs. 0.5%, P=0.018). Bleeding requiring re-intervention occurred more often in female patients with both asymptomatic (1.5% vs. 0.4%, P=0.045) and symptomatic carotid stenosis (2.4% vs. 0.2%, P=0.022). 30-day stroke/TIA and mortality rates were higher in female patients with both asymptomatic (stroke/TIA 4.4% vs. 2.5%, P=0.041; mortality 3.3% vs. 1.6%, P=0.046) and symptomatic carotid stenosis (stroke/TIA 8.3% vs. 4.2%, P=0.040; mortality 4.1% vs. 0.7%, P=0.006). After adjusting for all confounding factors, female gender remained an important predicting factor for 30-day stroke/TIA in asymptomatic (OR=1.4, 95%CI 1.0-4.7, P=0.041) and symptomatic patients (OR=1.7, 95%CI 1.1-5.3, P=0.040), as well as for 30-day all-cause mortality in patients with asymptomatic (OR=1.5, 95%CI 1.1-4.1, P=0.030) and symptomatic carotid artery disease (OR=1.2, 95%CI 1.0-5.2, P=0.048).

CONCLUSIONS

Female gender is important predicting factor for stroke/TIA and all-cause mortality, both perioperative and during the first 30 days after carotid surgery.

Editor's Choice - Sex Related Differences in Indication and Procedural Outcomes of Carotid interventions in VASCUNET

OBJECTIVE

It has been suggested that peri-operative complications after carotid surgery may be higher in women than in men. This assumption may affect the treatment patterns, and it is thus possible that carotid endarterectomy (CEA) is provided to women less often. The aim of the current VASCUNET study was to determine sex related differences in operative risk in routine clinical practice among non-selected patients undergoing carotid revascularisation.

METHODS

Data on CEA and carotid artery stenting (CAS) from 14 vascular registries were collected and amalgamated. Comprehensive data were available for 223 626 carotid artery procedures; these were analysed overall and by country. The primary outcome was any stroke and or death within 30 days of carotid revascularisation. Secondary outcomes were stroke, death, or any major cardiac event or haemorrhage leading to re-operation.

RESULTS

Of the procedures, 34.8% were done in women. The proportion of CEA for asymptomatic stenosis compared with symptomatic stenosis was significantly higher among women than men (38.4% vs. 36.9%, p < .001). The proportion of octogenarians was higher among women than men who underwent CEA in both asymptomatic (21.2% vs. 19.9%) and symptomatic patients (24.3% vs. 21.4%). In the unadjusted analysis of symptomatic and asymptomatic patients, there were no significant differences between men and women in the rate of post-operative combined stroke and or death, any major cardiac event, or combined death, stroke, and any major cardiac event after CEA. Also, after stenting for asymptomatic or symptomatic carotid stenosis, there were no significant differences between men and women in the rate of post-operative complications. In adjusted analyses, sex was not significantly associated with any of the end points. Higher age and CAS vs. CEA were independently associated with all four end points.

CONCLUSION

This study confirmed that, in a large registry among non-selected patients, no significant sex related differences were found in peri-operative complication rates after interventions for carotid stenosis.

An Analysis of Sex-Based Outcomes Following Transcarotid Artery Revascularization

OBJECTIVE

Several studies suggest that females have higher perioperative adverse events and decreased benefit from carotid artery revascularization with transfemoral carotid artery stenting and carotid endarterectomy (CEA) compared to males. However, there are limited data of sex-based outcomes for transcarotid artery revascularization (TCAR).

METHODS

A retrospective review of prospectively maintained system-wide TCAR databases was performed between December 2015-January 2022. Patients who underwent TCAR were stratified based on sex. Relevant demographics, medical conditions, anatomical characteristics, intra- and postoperative courses, and adverse events were captured.

RESULTS

729 patients underwent TCAR, 486 (66.6%) male and 243 (33.3%) female. Males were more likely to be diagnosed with coronary artery disease (56.9% vs 47.7%, P<.01) and were active smokers (30.4% vs 21.4%, P < .01). Age, symptomatic status, BMI, hypertension, hyperlipidemia, diabetes mellitus, arrhythmia, chronic obstructive pulmonary disease, history of myocardial infarction, heart failure with reduced ejection fraction <30%, end-stage renal disease and Charlson Comorbidity Index were similar. In the perioperative period, there was no significant difference in reintervention rates (1.6% vs 1.2%, P = .75), cranial nerve palsy (.6% vs .4%, P > .99), ipsilateral stroke (1.9% vs 3.3%, P = .29), stent thrombosis (.4% vs .8%, P > .99), myocardial infarction (0% vs 0%, P > .99) and death (1.2% vs 1.2%, P > .99). In follow-up, no significant difference was found in reintervention, ipsilateral stroke, contralateral stroke, myocardial infarction, in-stent restenosis >50%, stent thrombosis, and death.

CONCLUSIONS

Males and females did not have a statistically significant difference in outcomes when comparing ipsilateral stroke, in-stent thrombosis, conversion to CEA, and death after TCAR. However, our cohort comprised predominantly male patients and may conceal statistical significance as the females in our cohort did have a higher tendency toward developing complications. Future studies with a larger female cohort should be conducted to determine whether there is a true disparity of outcomes between the males and females undergoing TCAR.

Carotid artery stenting has similar outcomes in men and women

Background

The aim of carotid interventions is to prevent cerebrovascular events. Endovascular treatment (carotid-artery-stenting/CAS) has become established as an alternative to open surgery in some cases. Historically, female sex has been considered as a perioperative risk factor, however, there are few studies regarding this hypothesis when it comes to CAS.

Objectives

To analyze the CAS results in our center adjusted by sex.

Methods

A retrospective cohort study was designed, including patients with carotid atheromatosis operated at a single center from January 2016 to June 2019. Our objective was to compare cardiovascular risk, including myocardial infarction, stroke, and mortality, by sex. Follow-up rates of stent patency, restenosis, stroke, myocardial infarction, and death were reported.

Results

71 interventions were performed in 50 men (70.42%) and 21 women (29.57%). Mean age was 70.50 ± 10.72 years for men and 73.62 ± 11.78 years for women. Cardiovascular risk factors did not differ significantly between sexes. Mean follow-up was 11.28 ± 11.28 months. There were no significant differences in neurological events during follow-up. No adverse cardiological events were detected at any time. Regarding the mortality rate, during medium-term follow up there were 2 neurological related deaths with no significant differences between sexes (p=0.8432). Neither sex had higher rated of restenosis during long term follow-up (5.63% vs. 1.41%, p = 0.9693) or reoperation (1.41% vs. 1.41%, p = 0.4971). All procedures remained patent (<50% restenosis).

Conclusions

Despite the limitations of our study, CAS is a therapeutic option that is as effective and safe in women as in men. No sex differences were observed.

Red blood cell distribution width is associated with hypoperfusion in carotid endarterectomy under regional anesthesia

BACKGROUND

A subset of patients submitted to carotid endarterectomy under regional anesthesia develop intraoperative neurologic deficit during carotid artery crossclamping related to critical cerebral perfusion, which may be owing to low flow or embolic phenomena. This subgroup is deemed prone to worse outcomes, which highlights its clinical relevance. The main aim of this study was to identify clinical and hematological predictors for intraoperative neurologic deficit. The secondary aim was to evaluate the perioperative prognostic value of postcarotid artery crossclamping manifestations of cerebral ischemia.

METHODS

Between January 2012 to January 2020, patients submitted to carotid endarterectomy under regional anesthesia in a tertiary referral center who presented intraoperative neurologic deficit were prospectively and consecutively included. This group constituted 8% of the total carotid endarterectomy performed in the center during this timeframe. The control group of patients was the subsequent patient submitted to carotid endarterectomy without intraoperative neurologic deficit in a 1:1 ratio. Blood samples were collected before surgery (<2 weeks). Propensity score matching was used to identify well-matched pairs of patients.

RESULTS

A total of 180 patients were included, with 90 (50% of the cohort and 8% of total carotid endarterectomies) presenting intraoperative neurologic deficit associated to clamping. Mean age was 71.4 ± 9.27 years in the study group and 68.8 ± 8.36 years in the control group. The clinical variables presenting significance after multivariate analysis include: age (adjusted odds ratio: 1.04, 5-95% confidence interval, [1.003-1.078]; P = .034), obesity (adjusted odds ratio: 3.537 [1.445-8.658]; P = .006), lower ipsilateral carotid stenosis grade (adjusted odds ratio: 0.725 [0.525-0.997]; P = .049), and higher contralateral carotid stenosis grade (adjusted odds ratio: 1.266 [1.057-1.516]; P = .010). Red cell distribution width coefficient of variation demonstrated statistical significance in predicting intraoperative neurologic deficit with an adjusted odds ratio of 1.394 (1.076-1.805); P = .012. The 30-day stroke rate was significantly higher in the intraoperative neurologic deficit group, with an adjusted odds ratio of 5.13 (5-95% confidence interval [1.058-24.87]; P = .042) after propensity score matching. Postoperative complications (Clavien-Dindo ≥2) were also associated with intraoperative neurologic deficit (after propensity score matching adjusted odds ratio of 2.748 [5-95% confidence interval, 0.976-7.741]; P = .051).

CONCLUSION

In this study, increased red cell distribution width coefficient of variation demonstrated value to predict intraoperative neurologic deficit. Additionally, age, obesity, a lower degree of ipsilateral carotid stenosis, and a higher degree of contralateral carotid stenosis also demonstrated ability to predict intraoperative neurologic deficit. Moreover, intraoperative neurologic deficit was an independent risk factor for 30-day stroke and postoperative complications Clavien-Dindo ≥2.

The age- and sex-specific composition of atherosclerotic plaques in vascular surgery patients

BACKGROUND AND AIMS

The sex- and age-related differences in the composition of iliofemoral atherosclerotic plaques are largely unknown. Therefore, the aim of the current study is to gain insight into plaque composition across strata of age and sex in a large cohort of vascular surgery patients.

METHODS

Peripheral atherosclerotic plaques of patients who underwent iliofemoral endarterectomy (n = 790) were harvested between 2002 and 2014. The plaques were semi-quantitatively analyzed for the presence of lipid cores, calcifications, plaque hemorrhages (PH), collagen, macrophage and smooth muscle cell (SMC) content, and quantitatively for microvessel density. Patients were stratified by age tertiles and sex.

RESULTS

Ageing was independently associated with rupture-prone iliofemoral plaque characteristics, such as higher prevalence of plaque calcifications (OR 1.52 (95%CI:1.03-2.24) p = 0.035) and PH (OR 1.46 (95%CI:1.01-2.09) p = 0.042), and lower prevalence of collagen (OR 0.52 (95%CI:0.31-0.86) p = 0.012) and SMCs (OR 0.59 (95%CI:0.39-0.90) p = 0.015). Sex-stratified data showed that men had a higher prevalence of lipid cores (OR 1.62 (95%CI:1.06-2.45) p = 0.025) and PH (OR 1.62 (95%CI:1.16-2.54) p = 0.004) compared to women. These sex-differences attenuated with increasing age, with women showing an age-related increase in calcifications (p = 0.002), PH (p = 0.015) and decrease in macrophages (p = 0.005). In contrast, men only showed a decrease in collagen (p = 0.043).

CONCLUSIONS

Atherosclerotic iliofemoral plaques derived from men display more rupture-prone characteristics compared to women. Yet, this difference is attenuated with an increase in age, with older women having more rupture-prone characteristics compared to younger women.

Female Gender as a Risk Factor for Adverse Outcomes After Carotid Revascularization

BACKGROUND

We aim to identify gender differences in complications after carotid surgery. Our primary endpoint is the incidence of perioperative stroke, myocardial infarction, and mortality. Secondary endpoints include restenosis and reintervention rates.

METHODS

All patients undergoing carotid endarterectomy from July 2003 to May 2016 were reviewed. The Society for Vascular Surgery carotid reporting standards were used as a guideline for data collection.

RESULTS

Over 13 years, 9,585 patients with carotid disease were referred to our institution. A total of 690 procedures were performed (633 carotid endarterectomies, 54 carotid angioplasties and stenting, and 3 bypasses). Of these 633 carotid endarterectomy procedures, 31.8% (201) were in women and 68.2% (432) were in men. In the perioperative period, female gender was found to be an independent predictor of stroke (odds ratio [OR]: 8.597, 95% confidence interval [CI]: 0.967-76.429, P = 0.041), restenosis (OR: 2.103, 95% CI: 1.445-3.060, P < 0.001), and reintervention (OR: 6.448, 95% CI: 1.313-31.667, P = 0.019). Mortality and cardiac morbidity did not significantly differ between genders. Ten-year stroke-free survival was 98.0% in women and 99.1% in men (logrank P = 0.259). Ten-year restenosis-free survival was 77.6% (45 of 201) in women and 89.4% (45 of 425) in men (logrank P < 0.001). Ten-year reintervention-free survival was 97.0% in women and 99.5% in men (logrank P = 0.008). Female gender was not an independent predictor of myocardial infarction (P = 0.713) and mortality (P = 0.856), respectively. The mean follow-up time was 47.06 ± 37.48 months with a median follow-up time of 43 months (interquartile range: 14.0-72.5).

CONCLUSIONS

Female gender was an independent predictor of postoperative stroke, restenosis, and reintervention. Symptom status at the time of surgery and type of closure of the arteriotomy did not influence development of stroke in female patients.

Three-year outcomes after carotid artery revascularization: Gender-related differences

Objectives

Carotid artery stenosis is thought to cause up to 10% of ischemic strokes. Historically, carotid artery endarterectomy has shown a higher risk of perioperative adverse events for women. More recent trials reported conflicting results regarding the benefit of carotid artery endarterectomy and carotid artery stenting for men and women. The aim of the present retrospective study was to investigate the influence of gender on the short- (30 days) and long-term (3 years) outcomes of carotid artery endarterectomy and carotid artery stenting in a single centre.

Methods

From 2010 to 2017, 912 consecutive symptomatic and asymptomatic patients who underwent carotid artery endarterectomy (389, 42.7%) or carotid artery stenting (523, 57.3%) in a single institution had been evaluated to determine the influence of sex (540 men, 59.2%, vs. 372 women, 40.8%) on the outcomes after both revascularization procedures during three years of follow-up. The primary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the short-term follow-up. The secondary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the long-term follow-up.

Results

Mean clinical follow-up was 21.1 (16.1) months. Women had internal and common carotid artery diameters significantly smaller with respect to men. For peri-procedural outcomes, women undergoing carotid artery stenting had a higher risk of moderate (50–70%) restenosis (6 women, 2.9%, vs. 3 men, 1.0%). For long-term outcomes, women undergoing carotid artery endarterectomy had a higher rate of moderate restenosis (16 women, 16.3%, vs. 11 men, 7.6%). No significant differences in long-term outcomes were observed between men and women undergoing carotid artery stenting, even after stratification for baseline risk factors.

Conclusions

Contrary to previous reports, from this single-centre study, long-term risk of events seems to be higher in women who underwent carotid artery endarterectomy than in those who underwent carotid artery stenting, while fewer differences were observed in men.

Restenosis and risk of stroke after stenting or endarterectomy for symptomatic carotid stenosis in the International Carotid Stenting Study (ICSS): secondary analysis of a randomised trial

BACKGROUND

The risk of stroke associated with carotid artery restenosis after stenting or endarterectomy is unclear. We aimed to compare the long-term risk of restenosis after these treatments and to investigate if restenosis causes stroke in a secondary analysis of the International Carotid Stenting Study (ICSS).

METHODS

ICSS is a parallel-group randomised trial at 50 tertiary care centres in Europe, Australia, New Zealand, and Canada. Patients aged 40 years or older with symptomatic carotid stenosis measuring 50% or more were randomly assigned either stenting or endarterectomy in a 1:1 ratio. Randomisation was computer-generated and done centrally, with allocation by telephone or fax, stratified by centre, and with minimisation for sex, age, side of stenosis, and occlusion of the contralateral carotid artery. Patients were followed up both clinically and with carotid duplex ultrasound at baseline, 30 days after treatment, 6 months after randomisation, then annually for up to 10 years. We included patients whose assigned treatment was completed and who had at least one ultrasound examination after treatment. Restenosis was defined as any narrowing of the treated artery measuring 50% or more (at least moderate) or 70% or more (severe), or occlusion of the artery. The degree of restenosis based on ultrasound velocities and clinical outcome events were adjudicated centrally; assessors were masked to treatment assignment. Restenosis was analysed using interval-censored models and its association with later ipsilateral stroke using Cox regression. This trial is registered with the ISRCTN registry, number ISRCTN25337470. This report presents a secondary analysis, and follow-up is complete.

FINDINGS

Between May, 2001, and October, 2008, 1713 patients were enrolled and randomly allocated treatment (855 were assigned stenting and 858 endarterectomy), of whom 1530 individuals were followed up with ultrasound (737 assigned stenting and 793 endarterectomy) for a median of 4·0 years (IQR 2·3-5·0). At least moderate restenosis (≥50%) occurred in 274 patients after stenting (cumulative 5-year risk 40·7%) and in 217 after endarterectomy (29·6%; unadjusted hazard ratio [HR] 1·43, 95% CI 1·21-1·72; p<0·0001). Patients with at least moderate restenosis (≥50%) had a higher risk of ipsilateral stroke than did individuals without restenosis in the overall patient population (HR 3·18, 95% CI 1·52-6·67; p=0·002) and in the endarterectomy group alone (5·75, 1·80-18·33; p=0·003), but no significant increase in stroke risk after restenosis was recorded in the stenting group (2·03, 0·77-5·37; p=0·154; p=0·10 for interaction with treatment). No difference was noted in the risk of severe restenosis (≥70%) or subsequent stroke between the two treatment groups.

INTERPRETATION

At least moderate (≥50%) restenosis occurred more frequently after stenting than after endarterectomy and increased the risk for ipsilateral stroke in the overall population. Whether the restenosis-mediated risk of stroke differs between stenting and endarterectomy requires further research.

FUNDING

Medical Research Council, the Stroke Association, Sanofi-Synthélabo, and the European Union.

Sonographic Evaluation of Complications of Extracranial Carotid Artery Interventions

Carotid endarterectomy and carotid artery stenting are among the most common peripheral vascular procedures performed worldwide. Sonography is the initial and often only imaging modality used in the evaluation of iatrogenic carotid arterial injuries. This pictorial essay provides an overview of the clinical and sonographic findings of complications after interventions in the extracranial carotid arteries, including dissection, fluid collections, pseudoaneurysm, thrombosis, thromboembolism, restenosis, and stent deformation. Grayscale, color, and pulsed Doppler imaging findings are reviewed, and correlations with computed tomography, magnetic resonance imaging, and angiography are provided.

Risk of Inhospital Stroke or Death Is Associated With Age But Not Sex in Patients Treated With Carotid Endarterectomy for Asymptomatic or Symptomatic Stenosis in Routine Practice: Secondary Data Analysis of the Nationwide German Statutory Quality Assurance Database From 2009 to 2014

Background

Guideline recommendations on carotid endarterectomy are based predominantly on randomized, controlled trials, in which women or elderly patients are often under‐represented. This study analyzed the association of age and sex with the risk of in‐hospital stroke or death following carotid endarterectomy under routine conditions in Germany.

Methods and Results

Secondary data analysis using the Statutory German Quality Assurance Database on all carotid endarterectomy procedures (n=142 074) performed between 2009 and 2014. Primary outcome was any stroke or death until discharge; secondary outcomes were any in‐hospital stroke (alone), and death (alone). Descriptive statistics and multilevel multivariable regression analyses were applied. Patients were predominately male (68%), with mean age 71 years. Carotid stenosis was symptomatic in 40%. Primary outcome occurred in 1.8% of women and 1.9% of men. Multivariable regression analysis revealed that more‐advanced age was associated with a higher primary outcome rate (relative risk [RR] per 10‐year increase: 1.19; 95% CI, 1.14–1.24). Risk of death (alone) was associated with age (RR, 1.68; 95% CI, 1.54–1.84). Age was associated with the risk of stroke (alone; RR, 1.05; 95% CI, 1.00–1.11). Sex was not associated with primary outcome rate (1.01; 95% CI, 0.93–1.10), nor did it significantly modify the age effect.

Conclusions

This study shows that increasing age, but not sex, is associated with a higher risk of in‐hospital stroke or death following carotid endarterectomy under everyday conditions in Germany. Whereas the risk of death (alone) is significantly associated with age, the association between age and the risk of stroke (alone) can be considered of minor importance.

Meta- analysis and meta-regression analysis of the associations between sex and the operative outcomes of carotid endarterectomy

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.

Sex-associated differences in the modulation of vascular risk in patients with asymptomatic carotid stenosis

In this study, we aimed to identify determinants of the different sex-related stroke risk in subjects with asymptomatic internal carotid artery (ICA) stenosis. In all, 492 women (44.4%) and 617 men (55.6%), with unilateral ⩾ 60% asymptomatic ICA stenosis, were prospectively evaluated with a median follow-up of 37 months (interquartile range, 26 to 43). Vascular risk profile, plaque characteristics, stenosis progression, and common carotid artery intima-media thickness were investigated. Outcome measure was the occurrence of ischemic stroke ipsilateral to ICA stenosis. Myocardial infarction, contralateral stroke and transient ischemic attack were considered as competing events. The incidence rate of ipsilateral stroke over the entire follow-up period was 0.16%: 0.09% (95% confidence interval (CI) 0.05 to 0.15) in women and 0.22% (95% CI 0.17 to 0.29) in men (log-rank test, P<0.001). Stenosis progression significantly influenced the risk of ipsilateral stroke in both men (subhazard ratio, SHR, 8.99) and women (SHR 4.89). Stenosis degree (71% to 90%, SHR 2.35; 91% to 99%, SHR 3.38) and irregular plaque surface (SHR 2.32) were relevant risk factors for ipsilateral stroke only in men. Our findings suggest that characteristics of the stenosis and plaque exert a different effect in modulating vascular risk in the two sexes. Understanding sex differences in cardiovascular disease could help to target sex-specific future therapies.

High-Risk Anatomic Variables and Plaque Characteristics in Carotid Artery Stenting

Objectives:

To determine anatomic and plaque-related risk factors for patients undergoing carotid artery stenting.

Methods:

A retrospective review of patients from a prospectively maintained database undergoing carotid artery stenting at our institution between 2001 and 2010 was performed. Preoperative imaging studies (ie, ultrasound, computed tomography angiography, magnetic resonance angiography, and angiograms) were reviewed for specific anatomic criteria and plaque characteristics. Primary outcomes included 30-day stroke or transient ischemic attack (TIA). Secondary outcomes included 30-day death and myocardial infarction (MI). Statistical significance was assumed for P = .05.

Results:

Imaging was reviewed for 381 carotid arteries in 375 patients. There were 14 (3.7%) perioperative neurologic events, which included 8 TIA and 6 strokes. Thirty-day mortality and MI were 0.5% and 0.75%, respectively. Degree of internal carotid artery stenosis was associated with primary outcomes ( P = .03), and the presence of arch calcification trended toward an increase in primary outcomes ( P = .07). However, arch type, ostial involvement, tandem lesions, and plaque calcification did not correlate with primary outcomes. Differences were noted between the sexes, with females having more common carotid artery tortuosity than males (34% vs 27%, P = .04). Females also had a trend toward more plaque calcification and more severe arch calcification than males. These differences did not translate to differences in perioperative neurologic events.

Conclusion:

Our data suggest that degree of internal carotid artery stenosis and aortic arch calcification may be associated with increased perioperative neurologic risk during carotid stenting, but arch type is not.

Inflammatory mediators and cerebral embolism in carotid stenting: new markers of risk

PURPOSE

To investigate serological predictors of risk for cerebral embolism after carotid artery stenting (CAS).

METHODS

Twenty consecutive symptomatic and asymptomatic patients (13 men; mean age 74 years) with carotid artery stenosis undergoing standardized filter-protected CAS (Wallstent) were preoperatively evaluated to identify unstable plaque (duplex ultrasound), complicated aortic plaque (transesophageal echocardiography), and inflammatory status [high-sensitivity C-reactive protein (hs-CRP) and serum amyloid-A protein (SAA) serum levels]. Aortic arch type, carotid tortuosity, and complexity of the procedure were considered. Cerebral embolism was evaluated by comparing the number, volume, and side (ipsilateral and non-ipsilateral) of preoperative and postoperative cerebral lesions detected on diffusion-weighted resonance magnetic imaging (DW-MRI) and through light and scanning electron microscopy analysis of cerebral protection filters obtained from CAS.

RESULTS

All CAS procedures were completed with no complications. All patients had a negative preoperative DW-MRI, but at least 1 asymptomatic cerebral lesion appeared on DW-MRI after the procedure in 18 (90%) patients. Female gender was associated with a higher number of cerebral lesions (18.2±10.9 vs. 8.3±8.8 for men, p=0.03). Carotid plaque morphology, supra-aortic vessel anatomy, and procedure complexity did not correlate with number or volume of new cerebral lesions. Complicated aortic plaque was associated with a higher volume of non-ipsilateral cerebral lesions than uncomplicated plaque (235.0±259.3 vs. 63.6±63.2 mm(3), respectively; p=0.02). Hs-CRP ≥5 mg/L and SAA ≥10 mg/L were significantly associated with a higher number of new cerebral lesions [16.2±10.7 vs. 4.3±3.4 for hs-CRP <5 mg/L (p=0.02) and 14.8±10.3 vs. 2.8±3.4 for SAA <10 mg/L (p=0.006), respectively]. Hs-CRP ≥5 mg/L and SAA ≥10 mg/L also correlated with greater surface involvement by embolic materials in the protection filters at microscopic analysis [37.0% (5.1%) vs. 26.9% (2.5%) for hs-CRP <5 mg/L, p=0.004; 35.9% (13.5%) vs. 22.2% (6.9%) for SAA <10 mg/L, p=0.02].

CONCLUSION

In addition to female gender and the presence of complicated aortic plaque, inflammatory status can be a predictor of cerebral embolism in CAS.

Gender differences in hypertension: myths and reality

Life expectancy is longer in women compared to men, and cardiovascular events occur at a lower rate and at a later age in females than males. The impact of gender on the prevalence, the presentation, and the long-term outcome of cardiovascular disease has long been a topic of active research. Gender differences have been found in several studies but opposite findings also exist. The impact of gender in hypertension and antihypertensive therapy remains poorly clarified. The prevalence, awareness, treatment, and control rates of hypertension exhibit some differences between the two sexes, which are age-dependent. The female advantage in the cardiovascular risk of hypertensive patients might be attenuated by comorbidities and target organ damage. Another aspect of major clinical importance is whether gender differences exist on the effects of antihypertensive agents in blood pressure reduction and cardiovascular morbidity and mortality. The aim of this review is to critically evaluate recent data regarding gender differences in hypertension and incorporate new data into the body of existing knowledge.

Gender and Outcomes of Carotid Artery Interventions

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.

Gender-specific 30-day outcomes after carotid endarterectomy and carotid artery stenting in the Society for Vascular Surgery Vascular Registry

OBJECTIVE

Although the optimal treatment of carotid stenosis remains unclear, available data suggest that women have higher risk of adverse events after carotid revascularization. We used data from the Society for Vascular Surgery Vascular Registry to determine the effect of gender on outcomes after carotid endarterectomy (CEA) and carotid artery stenting (CAS).

METHODS

There were 9865 patients (40.6% women) who underwent CEA (n = 6492) and CAS (n = 3373). The primary end point was a composite of death, stroke, and myocardial infarction at 30 days.

RESULTS

There was no difference in age and ethnicity between genders, but men were more likely to be symptomatic (41.6% vs 38.6%; P < .003). There was a higher prevalence of hypertension and chronic obstructive pulmonary disease in women, whereas men had a higher prevalence of coronary artery disease, history of myocardial infarction, and smoking history. For disease etiology in CAS, restenosis was more common in women (28.7% vs 19.7%; P < .0001), and radiation was higher in men (6.2% vs 2.6%; P < .0001). Comparing by gender, there were no statistically significant differences in the primary end point for CEA (women, 4.07%; men, 4.06%) or CAS (women, 6.69%; men, 6.80%). There remains no difference after stratification by symptomatology and multivariate risk adjustment.

CONCLUSIONS

In this large, real-world analysis, women and men demonstrated similar results after CEA or CAS. These data suggest that, contrary to previous reports, women do not have a higher risk of adverse events after carotid revascularization.

Sex is associated with the presence of atherosclerotic plaque hemorrhage and modifies the relation between plaque hemorrhage and cardiovascular outcome

BACKGROUND AND PURPOSE

Plaque hemorrhage (PH) may lead to accelerated progression of atherosclerotic disease. The presence of local PH in the carotid plaque predicts future cardiovascular events in any vascular territory. We investigated the prevalence of local PH and the predictive value of PH for the occurrence of cardiovascular events in men and women separately.

METHODS

Atherosclerotic plaques from 1422 patients (969 men, 453 women) who underwent carotid endarterectomy were analyzed histologically for the presence of PH. Patients were monitored for 3 years for cardiovascular events (nonfatal stroke, nonfatal myocardial infarction, vascular death, and vascular intervention).

RESULTS

Plaques from men showed a significantly higher prevalence of PH compared with women (67% versus 54%; P<0.001). In 1353 patients with available follow-up data, with a median duration of 2.9 years, 270 events had occurred in men (29%) and 94 in women (22%). Stratified by presence of PH, the event rate was 32% in men with PH versus 23% in men without PH, and 23% in women with PH versus 21% in women without PH. A multivariable Cox proportional hazards model found a significant interaction between sex and PH. PH was significantly associated with events in men (adjusted hazard ratio, 1.9; 95% CI, 1.2-2.8) but not in women (adjusted hazard ratio, 1.0; 95% CI, 0.6-1.7).

CONCLUSIONS

Atherosclerotic carotid plaques obtained from men reveal a higher prevalence of PH compared with women. Local PH is strongly related to secondary manifestations of cardiovascular disease in men but not in women.

Female sex does not influence 30-day stroke and mortality rates after carotid endarterectomy

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.

Age and gender disparities in the risk of carotid revascularization procedures

The potential effect of age and gender stratification in the outcome of patients with carotid artery stenosis undergoing carotid revascularization procedures (CRP) may have important implications in clinical practice. Both European Stroke Organization and American Heart Association guidelines suggest that age and sex should be taken into account when selecting a CRP for an individual patient. We reviewed available literature data through Medline and Embase. Our search was based on the combination of terms: age, gender, sex, carotid artery stenosis, carotid artery stenting (CAS) and carotid endarterectomy (CEA). Postoperative stroke and mortality rates increased with age after any CRP (CEA or CAS), especially in patients aged over 75 years. Older patients with carotid artery stenosis undergoing CAS were found to have a nearly double risk of stroke or death compared with CEA, while CEA was found to benefit more patients aged over 70 years with symptomatic carotid artery stenosis. Male patients with symptomatic or asymptomatic carotid artery stenosis had lower stroke/mortality rates and benefited more from CEA compared with females. For the periprocedural risk of stroke or death in patients with carotid artery stenosis after CAS no sex differences were found. Therefore, CEA appears to have lower perioperative risks than CAS in patients aged over 70 years, and thus should be the treatment of choice if not contraindicated. The periprocedural risk of CEA is lower in men than in women, while there was no effect of gender on the periprocedural risk of CAS.

Sex differences of high-risk carotid atherosclerotic plaque with less than 50% stenosis in asymptomatic patients: an in vivo 3T MRI study

BACKGROUND AND PURPOSE

Men have a greater prevalence of high-risk carotid plaque features associated with stroke compared with women who have ≥50% stenosis, but little is known about these features in less significantly stenotic carotid arteries. This study aims to evaluate sex differences in complicated carotid plaque features in asymptomatic patients with <50% stenosis.

MATERIALS AND METHODS

Ninety-six patients (50 men, 46 women) with <50% carotid stenosis on MRA who had been referred for analysis of contralateral >50% carotid stenosis were included. The associations between sex and plaque features as identified by 3T MR carotid plaque imaging were examined by using logistic and linear regression models controlling for demographic characteristics, MRA stenosis, and the presence of contralateral plaque features.

RESULTS

The presence of a thin/ruptured fibrous cap (16% versus 2%, adjusted odds ratio = 8.57, P = .047), IPH (24% versus 6%, adjusted odds ratio = 4.53, P = .027), and American Heart Association type VI plaque (26% versus 6%, adjusted odds ratio = 5.04, P = .017) was significantly higher in men than in women. These associations remained significant following adjustment for contralateral plaque features. Men demonstrated a larger percentage volume of LR/NC (median, 1.66% versus -0.21%; P < .01). Calcification was not significantly associated with sex.

CONCLUSIONS

There is a sex difference of higher risk carotid plaque features during the early stage of disease seen in patients recruited for MR imaging evaluation of contralateral moderate-to-severe stenosis. Given the potential of using LR/NC without or with IPH to monitor therapy, these results indicate the possible importance of sex-based management in patients with asymptomatic carotid atherosclerosis across all stages of carotid stenosis.

In-hospital versus postdischarge adverse events following carotid endarterectomy

OBJECTIVE

Most studies based on state and nationwide registries evaluating perioperative outcome after carotid endarterectomy (CEA) rely on hospital discharge data only. Therefore, the true 30-day complication risk after carotid revascularization may be underestimated.

METHODS

We used the National Surgical Quality Improvement Program database 2005-2010 to assess the in-hospital and postdischarge rate of any stroke, death, cardiac event (new Q-wave myocardial infarction or cardiac arrest), and combined stroke/death and combined adverse outcome (S/D/CE) at 30 days following CEA. Multivariable analyses were used to identify predictors for in-hospital and postdischarge events separately, and in particular, those that predict postdischarge events distinctly.

RESULTS

A total of 35,916 patients who underwent CEA during 2005-2010 were identified in the National Surgical Quality Improvement Program database; 59% were male, median age was 72 years, and 44% had a previous neurologic event. Thirty-day stroke rate was 1.6% (n = 591), death rate was 0.8% (n = 272), cardiac event rate was 1.0% (n = 350), stroke or death rate was 2.2% (n = 794), and combined S/D/CE rate was 2.9% (n = 1043); 33% of strokes, 53% of deaths, 32% of cardiac events, 40% of combined stroke/death, and 38% of combined S/D/CE took place after hospital discharge. Patients with a prior stroke or transient ischemic attack had similar proportions of postdischarge events compared with patients without prior symptoms. Independent predictors for postdischarge events, but not for in-hospital events were female sex (stroke [odds ratio (OR), 1.6; 95% confidence interval (CI), 1.2-2.1] and stroke/death [OR, 1.4; 95% CI, 1.1-1.7]), renal failure (stroke [OR, 3.0; 95% CI, 1.4-6.2]) and chronic obstructive pulmonary disease (death [OR, 2.5; 95% CI, 1.6-3.7], stroke/death [OR, 1.8; 95% CI, 1.4-2.4], and S/D/CE [OR 1.8, 95% CI 1.4-2.3]).

CONCLUSIONS

With 38% of perioperative adverse events after CEA happening posthospitalization, regardless of symptoms status, we need to be alert to the ongoing risks after discharge particularly in women, patients with renal failure, or chronic obstructive pulmonary disease. This emphasizes the need for reporting and comparing 30-day adverse event rates when evaluating outcomes for CEA, or comparing carotid stenting to CEA.

Sex-related differences in carotid plaque features and inflammation

OBJECTIVE

Severe carotid stenosis is a frequent cause of stroke in both men and women. Whereas several sex-related comparisons are available on coronary atherosclerosis, there are few data appraising gender-specific features of carotid plaques. We aimed to systematically compare the pathology and inflammatory features of carotid plaques in men vs women.

METHODS

Carotid plaque specimens were collected from patients undergoing surgical endarterectomy for asymptomatic or symptomatic carotid stenosis. Histologic analysis was performed, as well as measurements of plaque composition and inflammation.

RESULTS

A total of 457 patients were included (132 women, 325 men). Baseline analyses showed a greater prevalence of hypercholesterolemia, hypertension, and former smoking status in women, despite a higher Framingham Heart Score in men (all P < .05). Women had a lower prevalence of thrombotic plaques, smaller percentage area of necrotic core, and hemorrhage extension (all P < .05). Plaque inflammation analysis showed a lower concentration of inflammatory and, in particular, of macrophage foam cells in the plaque cap of women (both P < .05). These differences were, however, no longer significant at multivariable analysis, including several baseline features, such as symptom status and stenosis severity.

CONCLUSIONS

Carotid plaques seem significantly different in women and men, but the main drivers of such pathologic differences are baseline features, including stenosis severity and symptom status.

Mapeamento ecográfico da bifurcação das artérias carótidas extracranianas para planejamento cirúrgico: diferenças baseadas no gênero do paciente

CONTEXTO: A ecografia das artérias carótidas extracranianas já se estabeleceu como método diagnóstico de imagem pré-operatória, e para seguimento de pacientes. OBJETIVO: Avaliar diferenças do mapeamento ecográfico em função do gênero masculino ou feminino dos pacientes. MÉTODOS: Ultrassonografia de alta resolução foi realizada antes do tratamento cirúrgico de 500 bifurcações carotídeas em 192 mulheres e 308 homens. Análise de diferenças baseadas no gênero foi feita em imagens modo B e fluxo a cor, transversal e longitudinal, e medidas duplex doppler de velocidades. Porcentual de estenose expressa em redução de diâmetro, comprimento de placa, diâmetros das artérias carótida interna distal e comum, e distância da bifurcação ao lóbulo da orelha foram comparados. Média, desvio padrão, mínimo e máximo foram descritos. Comparações estatísticas foram baseadas em testes t de Student e do Χ2. RESULTADOS: Estenoses carotídeas mediram 70±11% (30-95%) em mulheres e 72±12% (40-98%) em homens (p=0,013). Prevalência de estenoses no intervalo 90-99% foi mais alta em homens, 14,3 vs 7,8% (p=0,029). As placas foram mais extensas nos homens, 2,3±0,8 vs 1,9±0,6 cm (p<0,001). O diâmetro médio foi maior nos homens, tanto da carótida interna distal, 4,9±0,9 vs 4,6±0,8 mm, como da carótida comum, 7,6±1,3 vs 7,1±1,4 mm (p=0.001). A distância da bifurcação ao lóbulo da orelha foi maior nos homens, 5,9±1,1 vs 5,3±0,9 cm (p<0,001). CONCLUSÕES: O mapeamento ecográfico demonstrou que as medidas analisadas foram maiores em pacientes do gênero masculino. O planejamento detalhado do tratamento da placa carotídea deve considerar diferenças individuais como as associadas ao gênero do paciente.