IFT06 - Long-term Mortality in Patients Treated with Carotid Endarterectomy

Objectives: Few studies report on long-term mortality in carotid endarterectomy (CEA) treated patients and their mortality rate in comparison to the general population. The primary objective was to describe the long-term mortality in CEA-treated patients. The secondary objective was to evaluate if long-term mortality was different in asymptomatic or symptomatic carotid patients, and if sex differences were obvious. Also, their mortality rates were compared to the general population.

Methods: A non-randomized, observational two-center study in Stockholm, Sweden. The primary endpoint was mortality rate, crude and adjusted for asymptomatic and symptomatic patients. The secondary endpoints were mortality for symptomatic men and women and comparison of mortality with matched general population. Of n=1211 patients consecutively enrolled in Biobank of Karolinska Endarterectomies 1998-2017, n=1033 patients were included after exclusion of missing data entries. Individual data for death and comorbidities were extracted from national registries and clinical charts. Death at 1, 5 and 10 years, and mortality during follow-up was analyzed, with a 30-days wash-out period postoperatively. A Cox regression model was adapted, adjusting for variables with p-values <.10 in the univariate analysis. The standardized mortality ratio (SMR) was calculated with an age- and sex-matched population.

Results: 81% were symptomatic and 67% men. Mean follow-up was 6.6 years (0.09-19.31 years). The crude mortality at 1, 5 and 10 years was similar between asymptomatic and symptomatic CEA-treated patients (0.5% vs. 2.5%, p=0.09; 8.8% vs. 12.4%, p=0.16; 25.4% vs. 25.4%, p=0.99). In the multivariate analysis symptomatic carotid disease did not influence the mortality risk. Increasing age, male sex, ongoing smoking, diabetes and pulmonary disease were predictive factors (Table I). Among women the sex-specific adjusted model revealed increasing age, cardiac disease and ongoing smoking as risk factors, HR 9.89 (95%CI 3.21-30.42, p<.0001), HR 3.55 (95%CI 2.18-5.79, p<.0001) and HR 3.06 (95%CI 1.66-5.63, p<.0001). Among men lipid-lowering medication was protective, HR 0.61 (95%CI 0.39-0.96, p=.032), while cancer was predictive, HR 2.22 (95%CI 1.29-3.8, p=.004).
SMR was similar for asymptomatic and symptomatic CEA-treated patients. Within the first five years; asymptomatic, symptomatic, women and men had increased SMR, which diminished after five years (Table II).

Conclusions: Symptomatic and asymptomatic carotid patients show an equal long-term mortality after CEA, but all had worse long-term mortality than the general population. Especially men were at high risk for worse outcome, but beneficial effects was seen by lipid-lowering therapy. Targeted secondary prevention and refined patient selection strategies are obviously needed, to alter the long-term effects in CEA-treated patients.