Worse Outcomes Following Carotid Revascularization in Black Patients

Among individuals who receive carotid revascularization, non-Hispanic Black patients are significantly more likely to have worse in-hospital and long-term outcomes, even after accounting for socioeconomic status, according to a study in the Journal of Vascular Surgery.

Investigators sought to assess the association between race and ethnicity and clinical outcomes in patients who have had carotid endarterectomy, transfemoral carotid artery stenting, and transcarotid artery revascularization before and after accounting for socioeconomic status using the Area Deprivation Index (ADI).

Participants received carotid revascularization from January 2003 to February 2022. Data were from the Society for Vascular Surgery Vascular Quality Initiative carotid endarterectomy and carotid artery stenting databases. Patients who were Hispanic or a race other than Black or White were excluded.

The main study exposures were patient race and ADI, and the primary outcomes were in-hospital and long-term composite stroke or death.

Among 201,395 patients, 5.1% (mean age, 68.6±0.10 years; 51% women) were non-Hispanic Black patients and 94.9% (mean age, 70.9 ± 0.02 years; 38.2% women) were non-Hispanic White patients. They had a mean follow-up time of 3.4±0.01 years.

Compared with their White counterparts, a disproportionately increased percentage of Black patients were living in the most socioeconomically deprived neighborhoods (ADI-4, 38.5% vs 20.3%; P <.001). A comparison of crude in-hospital outcomes by race showed a significantly increased frequency of in-hospital stroke, death, and combined stroke and death occurring in Black patients vs White patients (all, P <.001).

Black race was associated with greater odds of in-hospital combined stroke and death after carotid artery revascularization compared with White race (adjusted odds ratio [aOR], 1.24; 95% CI, 1.10-1.40), after adjustment for standard demographic, comorbidity, and disease characteristics. This association was mostly similar after additional adjustment for ADI (Black vs White; aOR, 1.23; 95% CI, 1.09-1.39).

Black patients had an estimated 3-year risk for combined stroke and death of 12.0% (95% CI, 11.2-12.8) compared with 9.85% (95% CI, 9.69-10.0) for White patients (P <.001). Black race was significantly associated with an increased risk for combined stroke and death after carotid artery revascularization compared with White race after adjustment for standard demographic, comorbidity, and disease characteristics (adjusted hazard ratio [aHR], 1.13; 95% CI, 1.04-1.23). After additional adjustment for ADI, Black race continued to be associated with a greater risk for long-term combined stroke and death (aHR, 1.12; 95% CI, 1.03-1.21).

Participants who lived in more socioeconomically deprived neighborhoods (ADI-3 and ADI-4) had a significantly increased risk for long-term combined stroke and death vs patients who lived in the least socioeconomically deprived neighborhoods (both, P <.05).

Among several limitations, the Vascular Quality Initiative database is limited to centers that electively participate and thus may not be representative of general United States health care trends. In addition, the data are manually entered by physicians and subject to self-reporting bias, error, and limited to categorical variables in the dataset. Furthermore, ADI is the only composite measure of socioeconomic status, and the researchers were only able to analyze outcomes for Black and White patients.

“…we must recognize the possibility that gaps in our care and systems may prevent Black patients from experiencing equitable outcomes following carotid artery revascularization,” wrote the study authors. “In addition, Black patients undergoing carotid artery revascularization more frequently live in areas of higher socioeconomic deprivation compared to White patients.”