A recent study has pointed to an increased risk of stroke in both asymptomatic and symptomatic female patients, as well as readmission in asymptomatic female patients following carotid endarterectomy (CEA) or carotid artery stenting (CAS). These findings were published online ahead of print in the Journal of Vascular Surgery (JVS).
Authors Steven Goicoechea (Loyola University Medical Center, Chicago, USA) and colleagues write that, historically, CEA has illustrated a higher rate of perioperative adverse events for female patients. Despite this, they note that recent research portrays evidence to suggest similar outcomes following CEA between female and male patients. In contrast, however, they stress that few studies have examined sex differences in CAS.
In order to address this gap in the literature, Goicoechea et al prospectively collected contemporary data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, and performed a retrospective cross-sectional review.
The research team collected data from adult patients (n=106,658) who had undergone CEA (n=104,412) or CAS (n=2,156) in the period 2005–2017, they communicate in JVS.
The study’s primary outcomes of interest were 30-day postoperative adverse outcomes in asymptomatic versus symptomatic and female versus male patients, who had undergone CEA or CAS.
Among the asymptomatic group—in which nearly 60% of patients were male—female sex was associated with significantly higher rates of cerebrovascular accident (CVA; 32%, p=0.034), bleeding complication (203%, p=0.001), and urinary tract infection (70%, p=0.011) compared to male sex, the authors write.
Goicoechea and colleagues add that female sex was also associated with a lower rate of pneumonia (39%, p=0.039) and that female patients less than 75 years old illustrated increased rates of CVA (21%, p=0.001) and readmission (15%, p<0.001) compared to male patients, whereas this was not the case in female patients aged 75 years and older. Lastly, in both asymptomatic and symptomatic patients who received CEA, female patients had significantly higher rates of CVA (13% p=0.006 and 31%, p=0.044), however, these findings were not found in patients undergoing CAS.
In the discussion of their findings, Goicoechea et al write that the current study highlights sex disparities in vascular surgery, including discrepancies in postoperative outcomes and complications that have previously been established. They detail that women and ethnic minorities have historically been under-represented in vascular surgery randomised controlled trials (RCTs), especially in non-governmental and single-centre trials, commenting that this under-representation leads to under-reporting of potentially significant differences in outcomes between male and female patients.
Also in their discussion, the authors note that their study is limited by certain factors, including the use of retrospective data from an administrative dataset with potentially missing information, and difficulty identifying causes of discrepancies in female versus male outcomes due to a “lack of granularity” in a large database such as NSQIP.
In concluding, Goicoechea and colleagues stress that the present study emphasises the importance of understanding sex disparities in surgical management of cerebrovascular disease, and stress that RCTs must ensure adequate representation of female patients in order to better understand these differences.