Outcomes of redo vs primary carotid endarterectomy in the transcarotid artery revascularization era

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 transcarotid artery revascularization (TCAR) for restenosis after CEA compared with rCEA and transfemoral carotid artery stenting; however, not all patients are eligible for TCAR or transfemoral carotid artery stenting. 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 United States Food and Drug Administration in 2015.

Methods

All patients between 2003 and 2023 who underwent CEA in the Vascular Quality Initiative were included and categorized as pCEA or rCEA. Cochrane-Armitage trend testing was used to examine trends in proportion of rCEA compared with pCEA, and the Mann-Kendall trend test was used for perioperative outcomes following rCEA overtime. Multivariable logistic regression was used to compare in-hospital stroke/death, stroke, death, and stroke/death/myocardial infarction following rCEA vs pCEA after stratifying patients into two cohorts: 2003 to 2015 and 2016 to 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 Vascular Quality Initiative 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 to 2015, patients undergoing rCEA had higher odds of stroke/death compared with pCEA (2.4% vs 1.2%; adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 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; 95% CI, 1.19-3.25; P = .006); however, there was no difference in symptomatic patients (3.0% vs 2.0%; aOR, 1.37; 95% CI, 0.51;3.01; P = .50). In the late period, rCEA had higher odds of stroke/death compared with pCEA (3.1% vs 1.3%; aOR, 2.45; 95% CI, 1.85-3.18; P < .001), and the association was seen in asymptomatic patients (1.9% vs 1.0%; aOR, 1.95; 95% CI, 1.29-2.82; P < .001) and symptomatic patients (6.3% vs 2.0%; aOR, 3.23; 95% CI, 2.17-4.64; P < .001).

Conclusions

The proportion of rCEAs done yearly in the United States 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 Society for Vascular Surgery 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.