Outcomes of Redo vs Primary Carotid Endarterectomy in the TCAR Era.

Abstract

Objective: Outcomes following redo carotid endarterectomy (rCEA) have been shown to be worse than those after primary CEA (pCEA). Additional research has shown that outcomes are better with Trans Carotid Artery Revascularization (TCAR) for restenosis after CEA compared with rCEA and transfemoral Carotid Artery Stenting (tfCAS), however not all patients are eligible for TCAR or tfCAS. Given the increasing utilization of endovascular techniques, this study aims to evaluate changes in outcomes of rCEA vs pCEA before and after the approval of TCAR by the FDA in 2015.

Methods: All patients between 2003-2023 who underwent CEA in the VQI were included and categorized as pCEA or rCEA. Cochrane-Armitage trend testing was used to examine trends in proportion of rCEA compared to pCEA, and Mann-Kendall trend test for perioperative outcomes following rCEA overtime. Multivariable logistic regression was used to compare in-hospital stroke/death, stroke, death, and stroke/death/MI following rCEA versus pCEA after stratifying patients into two cohorts: 2003-2015 and 2016-2023 (before and after introduction of TCAR). Analysis was also performed based on preoperative symptoms.

Results: Of 198,150 patients undergoing CEA, 98.4% were pCEA and 1.6% were rCEA. During the study period the proportion of rCEA in the VQI decreased from 2.3% to 1.0% as endovascular methods became more available (p<.001). Trend testing of individual outcomes showed an increase in the stroke/death rate following rCEA over time (p=.019) despite an improvement in the death rate (p=.009). From 2003-2015 patients undergoing rCEA had higher odds of stroke/death compared to pCEA (2.4% vs 1.2%, aOR1.81[1.14,2.73], p=.007). Higher stroke/death rates after rCEA persisted only in asymptomatic patients (2.3% vs 1.1%, aOR 2.03[1.19,3.25], p=.006), however there was no difference in symptomatic patients (3.0% vs 2.0%, aOR1.37[0.51,3.01], p=.50). In the late period, rCEA had higher odds of stroke/death compared to pCEA (3.1% vs 1.3%, aOR2.45[1.85,3.18], p<.001), and the association was seen in asymptomatic patients (1.9% vs 1.0%, aOR1.95[1.29,2.82], p<.001) and symptomatic patients (6.3% vs 2.0%, aOR3.23[2.17,4.64], p<.001).

Conclusions: The proportion of redo-CEAs done yearly in the USA has been decreasing as endovascular options became available. As the rate of rCEA has decreased, outcomes have been worsening, with an increasing stroke/death rate seen over time, driven primarily by worse outcomes in symptomatic patients. Stroke/death rates for asymptomatic patients fall within SVS guidelines, and so the choice between rCEA, CAS, or medical management should be made after shared decision-making between a patient and their surgeon. However, with an in-hospital stroke death rate of over 6% symptomatic patients should be selected very carefully, as some are less likely to benefit from rCEA.