LAUSR

OBJECTIVES Society for Vascular Surgery (SVS) practice guidelines1 currently recommend carotid revascularization for asymptomatic disease in patients with at least a three-year life expectancy and stenosis > 60% when perioperative stroke and death rate is <3%. Based on this recommendation, it was previously determined that asymptomatic patients who are dialysis-dependent did not meet perioperative stroke and death thresholds, nor long-term survival benchmarks to justify carotid surgery. To determine if carotid surgery for patients on dialysis is appropriate, this study compared perioperative outcomes for dialysis-dependent patients relative to non-dialysis patients in a contemporary, national cohort following carotid revascularization. METHODS The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to identify patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS) for asymptomatic carotid disease from 2011-2018. The cohort was categorized as being dialysis-dependent, or non-dialysis dependent. Primary 30-day outcomes included mortality, composite stroke/death (SD) and stroke/death/myocardial infarction (SDM). Univariate analyses were performed using the Fisher's Exact test and the Wilcoxon rank-sum test. Multivariable analyses were used to assess the independent association of eGFR and dialysis-dependence on stroke/death rate. RESULTS A total of 17,579 patients met inclusion criteria. Two-hundred twenty-six (1.3%) were dialysis-dependent at the time of revascularization. There was no difference in degree of severe stenosis (80-99%) demonstrated by 69% of the dialysis cohort vs. 72% of the non-dialysis cohort (p=0.9). Five percent of dialysis vs. 3.6% non-dialysis patients received CAS (p=0.3). Dialysis-dependent patients were younger (68 vs. 71 years, p<0.001), more likely to have insulin-dependent diabetes (47% vs. 12%, p<0.001), congestive heart failure (8.4% vs. 1.4%, p<0.001) and severe COPD (15% vs. 10%, p=0.03). Comparing the dialysis vs. the non-dialysis cohorts, there were 2 (0.9%) vs. 88 (0.5%) deaths (p=0.3); 4 (1.8%) vs. 247 (1.4%) strokes (p=0.6); 3 (1.3%) vs. 185 (1.1%) MI (p=0.5). Composite outcomes of SD yielded 5 (2.2%) vs. 319 (1.8%, p=0.6); and SDM yielded 8 (3.5%) vs. 479 (2.8%, p=0.4). After multivariable analyses, eGFR status was not independently associated with the composite outcome of stroke/death (AOR 1.0, 95% CI: 1.00-1.01, p=0.26), nor was dialysis dependence (AOR 0.21 95% CI: 0.03-1.57, p=0.13). CONCLUSION Carotid revascularization 30-day outcomes for asymptomatic disease in dialysis-dependent patients do meet SVS guidelines in this national cohort and may be better than previously surmised. Hence, vascular surgeons may consider carotid revascularization in select dialysis-dependent patients with appropriate expected longevity and perioperative risk.