Carotid Endarterectomy: Race Associated with Surgical Delay

Patients at risk for stroke due to clinically significant carotid stenosis benefit from carotid endarterectomy (CEA), a procedure that prevents neurologic sequelae. The best surgical outcomes occur when patients undergo revascularization on diagnosis. Studies report that white patients are more likely to have CEA and experience good postoperative outcomes than black patients.

Patients at risk for stroke due to clinically significant carotid stenosis benefit from carotid endarterectomy (CEA), a procedure that prevents neurologic sequelae. The best surgical outcomes occur when patients undergo revascularization on diagnosis. Studies report that white patients are more likely to have CEA and experience good postoperative outcomes than black patients. Researchers from Vanderbuilt University and the University of Tennessee in Memphis hypothesized that black race is an independent risk factor for delayed CEA. Their results (which confirm the hypothesis) are published in the March 2015 issue of the Journal of Vascular Surgery.

This retrospective single institution study used data gathered between 1998 and 2013. The identified 166 CEA patients (32 black and 134 white) and screened for factors potentially affecting time from sonographic diagnosis of carotid stenosis warranting surgery to the day of operation (TDO). These included demographics, preoperative cardiac stress testing, extent of stenosis, smoking status, and comorbidities.

The mean TDO was 78 + 17 days for black patients, and 33 + 3 days for white patients.

Only 2 factors predicted prolonged TDO: the need for preoperative cardiac stress testing and black race.

Since clinical judgment guides CEA timing, and symptomatic patients who have high-grade stenosis are usually operated on with urgency, the researchers stratified patients by symptomatology (all, symptomatic, and asymptomatic patients). The association between black race and prolonged TDO held regardless of symptomatology.

The researchers note that they did not record or consider nonmedical variables (eg, insurance status, access to Medicare, socioeconomic factors )that might influence TDO. Other studies have considered these variables and found that they exert only a small influence.

The National Surgical Quality Improvement Program looked at CEA operations performed from 2005 to 2010 in a 2013 report, and linked black race to elevated risk of mortality. This study expands those finding to suggest that the delay between diagnosis and CEA could be a concern. The authors urge vascular surgeons to be aware of this disparity and counsel patients to avoid detrimental delays.