New data in the June 2011 issue of the Journal of Vascular Surgery®, the official publication of the Society for Vascular Surgery®, reveals that carotid endarterectomy (CEA) may be the preferred treatment for women who require intervention for cerebrovascular disease. The study notes that the results of cartoid angioplasty and stenting (CAS) have not been extensively analyzed in female patients.

According to Caron B. Rockman, MD, lead author and Associate Professor of surgery at New York University Medical Center in New York City, a total of 54,658 cases were reviewed from the Nationwide Inpatient Sample between 2004 and 2005. "A total of 94.2 percent of the patients had CEA while 5.8 percent had CAS," said Dr. Rockman. "Women comprised 42.3 percent of the analyzed cases and were significantly less likely to undergo CAS than men (5.4 percent vs. 6.1 percent)."

Despite concerns from early randomized trials that women might have higher rates of complications than men after undergoing CEA, in the current study, researchers noted that women and men had equivalent rates of perioperative stroke when undergoing CEA (1.0 percent vs. 1.0 percent) and CAS (2.7 percent vs. 2.0 percent).

Overall, women and men were equally likely to be symptomatic with a previous TIA (transient ischemic attack) or stroke before undergoing their carotid artery procedure (5.3 percent vs. 5.3 percent). It was noted that symptomatic women had a significantly higher overall rate of perioperative stroke than symptomatic men (3.8 vs. 2.3 percent). Dr. Rockman added that although women had a slightly higher complication rate, it was still well within the acceptable range for symptomatic patients undergoing cerebrovascular intervention.

More importantly, asymptomatic women had a significantly lower perioperative stroke rate after CEA than after CAS (0.9 percent vs. 2.1 percent). Rates of perioperative stroke additionally showed a trend favoring CEA as opposed to CAS among symptomatic women (3.4 percent vs. 6.2 percent) as well.

Researchers noted that the benefit of CEA in female patients has been questioned by various randomized, prospective trials particularly in asymptomatic cases; several have noted an increase in perioperative stroke among women after CEA. However, they added that the outcome of carotid angioplasty and stenting had not been extensively examined in women.

"An unexpected finding from our current analysis was that there appears to be a sex-based selection bias with regard to the type of carotid intervention performed," said Dr. Rockman. "Men were more likely to undergo CAS than women (6.1 percent vs. 5.4 percent) and asymptomatic men were more likely to undergo CAS than asymptomatic women (5.8 percent vs.4.8 percent). In contrast to these findings, symptomatic male patients were less likely to undergo CAS than symptomatic female patients (11.9 percent vs. 13.5 percent)." The precise reasons for these potential biases remain unclear at this time.

"Our analysis reveals that the concern regarding an increased perioperative stroke rate after CEA among asymptomatic women appears to be unfounded," added Dr. Rockman. "Overall, regardless of symptomatic status or the procedure performed, female patients undergoing carotid intervention had a nearly equivalent outcome compared with their male counterparts. Our findings suggest that women do not have an increased rate of perioperative complications as compared to men after intervention for carotid occlusive disease and that the indications for carotid intervention should not be influenced by their sex." Furthermore, CEA may be the preferred treatment in women who warrant intervention for cerebrovascular disease unless compelling reasons exist to perform CAS.

Society for Vascular Surgery