To review the sex differences among symptomatic and asymptomatic patients treated with carotid endarterectomy (CEA) and carotid stenting (CAS) in the Southeastern Vascular Study Group (SEVSG), a regional quality group of the Vascular Quality Initiative (VQI).
All cases reported by the SEVSG members of symptomatic and asymptomatic patients were included in this retrospective review of CEA and CAS. Primary end point was 3-year survival difference between male and female patients. Secondary end points included in-hospital myocardial infarction (MI), transient ischemic attack(TIA)/stroke and mortality differences between symptomatic and asymptomatic male and female patients. Cox proportional hazard regression was utilized to assess 3-year survival differences.
There were 8303 CEA and 1876 CAS procedures performed in 29 centers from January 2011 to December 2018. From those, 4650 (56.0%) and 938 (50.1%) were asymptomatic CEA and CAS, respectively. There were 2760 (59.4%) male patients in the asymptomatic CEA and 597 (63.9%) in the asymptomatic CAS groups. After CEA, the rates of in-hospital MI (p=0.034), TIA/stroke (p<0.001) and death (p<0.001) were significantly higher in symptomatic patients. MIs were more frequent in females with asymptomatic disease (p=0.041). After CAS, the rate of TIA/stroke was higher in symptomatic patients (p=0.030). There were no differences according to sex in the CAS group. On follow-up, asymptomatic male patients treated with CAS had a higher 3-year all-cause mortality compared to their female counterparts (7.0% vs. 1.8%; p=0.015). On multivariable Cox-regression analysis, male sex (HR=2.63 [95% CI=1.058-6.536]; p=0.038) and lower hemoglobin levels (HR=0.72 [95% CI=0.597-0.857]; p<0.001) were predictors of death in asymptomatic male patients treated with CAS.
In our SEVSG region, post-operative MIs, TIA/stroke and deaths were higher in symptomatic CEA patients. MIs were more frequent in asymptomatic CEA females. Post-operative TIA/stroke were more frequent in symptomatic CAS patients. After CAS, asymptomatic male patients had higher 3-year all-cause mortality than female patients. On multivariable Cox-regression analysis, male sex and lower hemoglobin levels were predictors of death in these asymptomatic male patients treated with CAS. Long-term mortality risk in asymptomatic males should be considered prior to offering CAS. Further national VQI analysis of our asymptomatic and symptomatic male and female patients treated with CEA and CAS would be warranted.

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