Risks associated with primary and redo carotid endarterectomy in the endovascular era

IMPORTANCE Clinical experience suggests worse outcomes for redo carotid endarterectomy (CEA) relative to primary CEA. Objective quantification of the excess risk attributable to redo CEA in this era of proliferating endovascular therapy remains to be determined. OBJECTIVE To evaluate the risks of redo CEA relative to primary CEA. DESIGN, SETTING, AND PARTICIPANTS This studywas a retrospective analysis of a prospective cohort of patients maintained by the Society for Vascular Surgery in the Vascular Quality Initiative between January 1, 2003, and April 30, 2016. The setting was consecutive patients from academic and community hospitals across the United States. Participants were patients who underwent primary CEA or redo CEA for symptomatic or asymptomatic carotid stenosis. EXPOSURES Primary CEA and redo CEA. MAIN OUTCOMES AND MEASURES Stroke, death,myocardial infarction, stroke or death, and stroke, death, ormyocardial infarction at 30 days and 1 year. RESULTS There were 64 118 CEAs recorded, including 62 749 primary CEAs (97.9%) (median age, 71 years; 39.5%female) and 1369 redo CEAs (2.1%) (median age, 71 years; 42.2% female). Comparing primary CEA vs redo CEA, the incidence of 30-day stroke was 0.7%vs 1.9% (P < .001) for asymptomatic patients and 1.5%vs 1.4%(P = .77) for symptomatic patients for an overall 0.9%vs 1.8%(P = .002). Incidences were 0.8%vs 1.3%(P = .09) for perioperativemyocardial infarction, 0.6%vs 1.4%(P = .003) for death, and 1.5%vs 2.6% (P = .001) for stroke or death. Risk-adjusted 30-day stroke (odds ratio [OR], 2.82; 95%CI, 1.69-4.71; P < .001), death (OR, 2.15; 95%CI, 1.21-3.79; P = .009), and stroke or death (OR, 2.06; 95%CI, 1.32-3.23; P = .002) were higher for redo CEA compared with primary CEA among asymptomatic patients but were similar among symptomatic patients for stroke (OR, 0.79; 95%CI, 0.33-1.95; P = .62), death (OR, 1.32; 95%CI, 0.53-3.26; P = .55), and stroke or death (OR, 0.85; 95%CI, 0.39-1.82; P = .68). Stroke or death at 1 year among asymptomatic patients was higher for redo CEA (hazard ratio [HR], 1.36; 95%CI, 1.08-1.69; P = .009) but was similar among symptomatic patients (HR, 0.94; 95%CI, 0.67-1.31; P = .71). CONCLUSIONS AND RELEVANCE The outcomes of redo CEA and primary CEA fall within the professional guidelines for carotid revascularization. However, redo CEA is associated with a 2.8 times increase in the risk of stroke and a 2.2 times increase in the risk of death compared with primary CEA among asymptomatic patients. There is no significant difference in outcomes among symptomatic patients. These redo CEA and primary CEA results should inform patient and clinician expectations at the point of care.