Trends and Outcomes of Carotid Revascularization for ACAS in ESKD Patients on Dialysis from 2010-2019

INTRODUCTIONThe role of carotid revascularization for asymptomatic carotid artery stenosis (ACAS) in dialysis-dependent end-stage kidney disease (ESKD) patients remains poorly defined, as these patients have high periprocedural risks and limited long-term survival. This study evaluated the trends in carotid revascularization in this group and studied associated short- and long-term outcomes. METHODSWe analyzed the United States Renal Data System (USRDS) to study dialysis-dependent ESKD patients with ACAS who underwent carotid endarterectomy (CEA) or carotid artery stenosis (CAS) between 2010 and 2019. Primary outcomes included trends in CEA and CAS utilization, 30-day stroke or death rates. Secondary outcomes were in-hospital and one-year stroke or death rates. RESULTSAmong 11,405 ESKD patients on dialysis with ACAS, 4954 underwent carotid revascularization (4098 CEA; 856 CAS). CEA rates reduced by 55% and CAS by 50% between 2010 and 2019. CAS was associated with a higher 30-day composite stroke or death rate (7.13% vs 4.5%; P=0.0014), in-hospital stroke or death rate (3.39% vs 2.22%, P=0.0433), and 1-year stroke or death rate (33.1% vs 25.4%, P<0.001) compared to CEA. No significant improvements in the outcomes over time were observed. CONCLUSIONCarotid revascularization rates for ACAS have declined among dialysis-dependent ESKD patients, yet both CEA and CAS are associated with significant procedure-related stroke and death risk. These support a cautious approach and underscore the need for a more selective and individualized shared decision-making approach in this high-risk population.