Carotid endarterectomy and transcarotid artery revascularization can be performed with acceptable morbidity and mortality in patients with chronic kidney disease

Objective:Patients with chronic kidney disease (CKD) are considered a high-risk population, and the optimal approachto the treatment of carotid disease remains unclear. Thus, we compared outcomes following carotid revascularization forpatients with CKD by operative approach of carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS),and transcarotid arterial revascularization (TCAR).Methods:The Vascular Quality Initiative was analyzed for patients undergoing carotid revascularizations (CEA, TFCAS, andTCAR) from 2016 to 2021. Patients with normal renal function (estimated glomularfiltration rate>90 mL/min/1.72 m(2))were excluded. Asymptomatic and symptomatic carotid stenosis were assessed separately. Preoperative demographics,operative details, and outcomes of 30-day mortality, stroke, myocardial infarction (MI), and composite variable of stroke/death were compared. Multivariable analysis adjusted for differences in groups, including CKD stage.Results:A total of 90,343 patients with CKD underwent revascularization (CEA, n 1/4 66,870; TCAR, n 1/4 13,459; and TFCAS,n 1/4 10,014; asymptomatic, 63%; symptomatic, 37%). Composite 30-day mortality/stroke rates were: asymptomatic: CEA,1.4%; TCAR, 1.2%; TFCAS, 1.8%; and symptomatic: CEA, 2.7%; TCAR, 2.3%; TFCAS, 3.7%. In adjusted analysis, TCAR had lower30-day mortality compared with CEA (asymptomatic: adjusted odds ratio [aOR], 0.4; 95% confidence interval [CI], 0.3-0.7;symptomatic: aOR, 0.5; 95% CI, 0.3-0.7), and no difference in stroke, MI, or the composite outcome of stroke/death in bothsymptom cohorts. TCAR had lower risk of other cardiac complications compared with CEA in asymptomatic patients(aOR, 0.7; 95% CI, 0.6-0.9) and had similar risk in symptomatic patients. Compared with TFCAS, TCAR patients had lower30-day mortality (asymptomatic: aOR, 0.5; 95% CI, 0.2-0.95; symptomatic: aOR, 0.3; 95% CI, 0.2-0.4), stroke (symptomatic:aOR, 0.7; 95% CI, 0.5-0.97), and stroke/death (asymptomatic: aOR, 0.7; 95% CI, 0.5-0.97; symptomatic: aOR, 0.6; 95% CI,0.4-0.7), but no differences in MI or other cardiac complications. Patients treated with TFCAS had higher 30-day mortality(aOR, 1.8; 95% CI, 1.2-2.5) and stroke risk (aOR, 1.3; 95% CI, 1.02-1.7) in symptomatic patients compared with CEA. There wereno differences in MI or other cardiac complications.Conclusions:Among patients with CKD, TCAR and CEA showed rates of stroke/death less than 2% for asymptomaticpatients and less than 3% for symptomatic patients. Given the increased risk of major morbidity and mortality, TFCASshould not be performed in patients with CKD who are otherwise anatomic candidates for TCAR or CEA. (J Vasc Surg2024;80:431-40.)