Carotid Endarterectomy in Patients with Renal Insufficiency: Should Selection Criteria be Different in Patients with Renal Insufficiency?

Abstract

The objective of this study was to elucidate the relationship between outcomes from carotid endarterectomy (CEA) in patients with and without renal insufficiency. Carotid endarterectomy is one of the most commonly performed vascular procedures. The role of cardiac comorbidity in carotid endarterectomy has been extensively studied. The relationship between renal failure and surgical outcomes has also been studied for both coronary artery bypass grafting and lower extremity occlusive disease. However, the role of renal insufficiency in relationship to decision making regarding surgical intervention for carotid stenosis is not well defined. The authors hypothesized that the outcomes from CEA were negatively influenced by renal dysfunction. A retrospective review was made of consecutive CEAs performed at their institution from 1990 to 1995. Patients were grouped into 2 categories according to their renal function. Group A, 448 patients (90%) with creatinine level 1.8 mg/dL or less, and group B, 49 patients (10%) with creatinine levels more than 1.8 mg/dL. Data from patients on dialysis are presented but were excluded for the purpose of analysis. Included in the study were 497 patients with a mean age of 70 +/-8.9 and 74 +/-8.9 for groups A and B, respectively. Preoperative creatinine was 1.1 (+/-0.25) mg/dL for group A and 2.5 (+/-0.81) mg/dL for group B. Outcomes were as follows: perioperative cardiac events 5.4% vs 28.6%, stroke rates 2.7% vs 2.0%, and mortality rates 0.9% vs 8.2%, for groups A and B, respectively. At 60-month follow-up the stroke rates were 7.6% vs 6.1 %, and the mortality rates 22.8% vs 59.2%, for groups A and B, respectively. While patients with chronic renal insufficiency have no increased risk of perioperative or long-term neurologic events, perioperative and long-term mortality rates are significantly increased. This significant reduction in survival should prompt a more cautious application of CEA in patients with increased creatinine.

The impact of renal insufficiency on the outcome of carotid surgery is influenced by the definition used

“…In 497 patients separated according to the level of creatininemia Ͻ 1.8 mg/dL (n ϭ 448) or Ͼ 1.8 mg/dL (n ϭ 49), Ayerdi et al 14 reported an incidence of MI of 5.4% and 28.6%, an incidence of postoperative stroke of 2.7% and 2.0%, and mortality of 0.9% and 8.2%, respectively, thus confirming the negative impact of RI on the results of carotid surgery.…”

“…[5][6][7][8][9][10][11][12][13] These studies used different definitions of renal insufficiency (RI). Certain authors used plasma levels of creatinine to define groups of patients, 5,7,8,10,14 others considered that creatinine clearance gave a better assessment of renal function, 1 and others associated the two. 9 Furthermore, different levels were used to constitute the groups.…”

A contemporary evaluation of carotid endarterectomy outcomes in patients with chronic kidney disease in the United States

“…There have been several studies which have evaluated the impact of ESRD on patients undergoing CEA; however, the conclusions from these analyses have been varied. [7][8][9] This study found that patients with ESRD were three times more likely to die compared to NF patients as at greater risk for respiratory and septic complications. Okawa et al reported disparate conclusions in a small retrospective chart review.…”

“…There have been varied conclusions reported on the risks of CKD in patients undergoing CEA, from no increase in risk to a detrimental increase in complications and death. [7][8][9][10][11][12][13][14][15][16][17] The objective of this analysis was to evaluate the morbidity and mortality of CEA in patients with ESRD and CKD utilizing the Nationwide Inpatient Sample (NIS) database.…”

Impact of chronic kidney disease on carotid plaque vulnerability

“…This method, however, does not allow for the reliable quantification of calcification and plaque vulnerability. 5,7,13 Degradation of the vessel wall, particularly by matrix metalloproteinases (MMPs), together with an increased inflammatory reaction, are the main reasons for plaque progression toward rupture and consequent neurologic symptoms. [14][15][16] Furthermore, several studies and our own data have already demonstrated increased levels of MMPs in the blood of patients with advanced carotid atherosclerosis.…”