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Background: Carotid endarterectomy (CEA) for asymptomatic carotid artery disease is advised for patients with low perioperative stroke risk and life expectancy of 3-5 years. We sought to explore the role of risk stratification and postoperative medical management in identifying appropriate asymptomatic candidates for CEA in the end-stage kidney disease (ESKD) population., Methods: We identified ESKD patients on dialysis from the United States Renal Data System that underwent CEA (2008-2014) for asymptomatic carotid artery disease. We used the Liu comorbidity index as well as a novel risk prediction model based on Cox proportional hazards model to stratify patients. The primary outcome evaluated was 3-year survival, and Kaplan-Meier methods were used to generate survival estimates. We further conducted a subanalysis of patients with Medicare part D data to determine postoperative usage of the following medications: statins, antiplatelets, and antihypertensives. We evaluated the association of medication utilization and 3-year survival using Kaplan-Meier methods and Cox proportional hazards modeling., Results: We analyzed 1,813 patients meeting inclusion criteria. The population was predominantly older (mean age 70.2 ± 9.1), White (84.8%), and had a high prevalence of cardiovascular comorbidities, such as hypertension (90.7%), diabetes (62.5%), and congestive heart failure (35.4%). Among the entire cohort, 23.0% had a Liu comorbidity index ≤8, 35.0% had index 9-12, and 42.0% had index >12. Increasing Liu comorbidity index was associated with worse survival (P < 0.01); however, even the group with Liu index ≤8 had poor 3-year survival of 58.8% (53.9-63.4). The Cox proportional hazards model identified variables for inclusion in the risk model such as age >80 (adjusted hazard ratio [aHR] = 2.49, 95% confidence interval [CI] [1.87-3.33], P < 0.001), congestive heart failure (aHR = 1.31, 95% CI [1.14-1.51], P < 0.001), and Liu comorbidity index >12(aHR = 1.89, 95% CI [1.56-2.28], P < 0.001). The risk score generated ranged from 0 to 6.5, and patients were divided into 3 groups: score ≤2 (43.4%), 2-4 (41.2%), and >4 (15.4%). Increasing risk score was associated with worse survival (P < 0.01) but even the "low-risk" group had 3-year survival of 58.5% (54.9-61.9). Subanalysis of the 1,249 (68.8% of total) patients with part D data found that statins and calcium channel blocker use was associated with improved survival, although observed rates for patients on drug were still low., Conclusions: The overall long-term survival of ESKD patients undergoing CEA for asymptomatic carotid artery disease is low. Risk stratification and analysis of postoperative medical management did not identify a subgroup of patients with adequate 3-year survival. Hence, the preventive benefits of CEA are not realized in these patients., (Copyright © 2023. Published by Elsevier Inc.)

Background: Elderly patients represent a large portion of patients undergoing vascular surgery. This study aims to assess the contemporary frequency of octogenarians undergoing carotid endarterectomy (CEA) and to evaluate their postoperative complications and survival rates., Methods: The Vascular Quality Initiative (VQI) dataset was queried for patients who underwent elective CEA between 2012 and 2021. Patients aged >90 years were excluded, as well as emergent and combined cases. The population was divided into two age groups: <80 years and ≥80 years. Frailty scores were generated using Vascular Quality Initiative variables grouped into 11 domains historically associated with frailty. Patients with scores within the first 25th percentile, between the 25th and 50th percentile, and above the 75th percentile were categorized into low, medium, and high frailty classes, respectively. Procedural indications were defined as hard (stenosis ≥80% or ipsilateral neurologic symptoms) or soft. Primary outcomes of interest were 2-year stroke-free and 2-year overall survival comparing (i) octogenarians with nonoctogenarians and (ii) octogenarians by frailty class. Standard statistical methods were used., Results: Overall, 83,745 cases were included in this analysis. Between 2012 and 2021, a consistent proportion averaging 17% of CEA patients were octogenarians. Among this age group, the proportion of patients undergoing CEA for hard indications increased over time from 43.7% to 63.8% (P < .001). This increase was accompanied by a statistically significant increase in the combined 30-day perioperative stroke and mortality rate from 1.56% in 2012 to 2.96% in 2021 (P = .019). A Kaplan-Meier analysis showed a significantly lower 2-year stroke-free survival among octogenarians compared with the younger group (78.1% vs 87.6%; P < .001). Similarly, there was a significantly lower 2-year overall survival among octogenarians compared with the younger group (90.5% vs 95.1%; P < .001). Multivariate Cox proportional hazard analyses showed that high frailty class was associated with increased 2-year stroke risk (hazard ratio, 2.26; 95% confidence interval, 1.61-3.17; P < .001) and 2-year mortality (hazard ratio, 2.43; 95% confidence interval, 1.71-3.47; P < .001). Repeat Kaplan-Meier analysis stratifying octogenarians by frailty class revealed that octogenarians with low frailty can have stroke-free and overall survival rates comparable with nonoctogenarians (88.2% vs 87.6% [P = .158] and 96.0% vs 95.1% [P = .151], respectively)., Conclusions: Chronological age should not be regarded as a contraindication for CEA. Frailty score calculation is a better predictor for postoperative outcomes and is an appropriate tool to risk stratify octogenarians, aiding in the decision between best medical treatment or intervention. The risk benefit assessment for high frailty class octogenarians is paramount because the postoperative risks may outweigh the long-term survival benefits of the prophylactic CEA., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Carotid revascularization is performed to prevent cerebrovascular events in patients with symptomatic (>50%) and asymptomatic high degree (>70%) carotid stenosis. As this operation carries significant risks for perioperative stroke, careful selection of patients who will benefit from the procedure is essential. Certain plaque characteristics, including texture, are associated with increased tendency for rupture and can be used to identify high-risk patients. Medical therapy, carotid endarterectomy, and carotid stenting are the mainstays for patient management. With careful selection of patients, all anesthesia techniques (general anesthesia, monitored anesthesia care, and regional anesthesia) can be used safely for these revascularization procedures., (Copyright © 2022 Elsevier Inc. All rights reserved.)