Carotid Endarterectomy in Women: Challenging the results from NASCET and ACAS.
Purpose: The randomized trials have clearly demonstrated the benefits of carotid endarterectomy in specific symptomatic and asymptomatic patients. However, the short and long-term benefits in women appear to be less clear, and the role of CEA among women remains uncertain. The purpose of our study was to evaluate and compare the outcomes in women and men after CEA. Methods: Over a recent 21 year period 1204 CEAs were performed, of which 465 (39%) were in women and 739 (61%)in men. Complete follow-up was available in 80% of patients. Results: Women were more likely to be hypertensive, and had a greater incidence of diabetes. The mean age at CEA was 68.5 ± 9.5 years for women and 68.0 ± 8.5 years for men. Operative mortality rates were nearly identical for symptomatic (women, 0.3% vs men, 0.8%) and asymmptomatic (women, 0.0% vs 0.8%)patients. Perioperative stroke rates were similar for symptomatic (women, 2.9% vs 4.5%) (p=0.27) and asymptomatic (women, 0.6% vs. men, 1.2%) (p=0.66) patients. Life-table stroke-free rates at 1, 5, and 8 years were similar for symptomatic women and men, 96% vs. 93%, 89% vs. 89%, and 83% vs. 85% (p>0.10), and asymptomatic women and men, 98% vs. 97%, 97% vs. 92%, and 97% vs. 86% (p>0.11). Long-term survival rates at 1, 5, and 8 years were higher for symptomatic women compared to men, 96% vs. 92%, 88% vs. 76%, and 67% vs. 58% (p=0.06), and for asymptomatic women as compared to men, 97% vs. 96%, 92% vs. 75%, 79% vs. 58% (p=0.01 > 5 years). As a result, stroke-free survival rates at these follow-up intervals were increased for symptomatic women compared to men, 93% vs. 89%, 76% vs. 73%, and 64% vs. 58% (p>0.11), and asymptomatic women as compared to men, 95% vs. 93%, 89% vs. 76%, and 77% vs. 64% (p>0.07). Conclusion: The results from our study challenge the conclusions from the NASCET and ACAS regarding the lack of benefit of CEA in women. Female gender did not adversely affect early or late survival, stroke-free, or stroke-free mortality rates following CEA. We conclude that CEA can be performed safely in women with symptomatic and asymptomatic carotid artery disease, and physicians should expect comparable benefits in women and men undergoing CEA.