What are the primary risk factors for an elderly female patient with chronic kidney disease (CKD) and diabetes undergoing carotid endarterectomy?

Risk Factors for Carotid Endarterectomy in Elderly Females with CKD and Diabetes

An elderly female with CKD and diabetes faces significantly elevated perioperative risks for carotid endarterectomy, with chronic kidney disease being the most critical risk factor—particularly if severe (creatinine >2.9 mg/dl)—followed by female sex, advanced age, and diabetes with chronic complications.

Primary Risk Factors by Severity

Chronic Kidney Disease (Highest Impact)

Severe CKD (creatinine >2.9 mg/dl) carries a 43% combined stroke and death rate after CEA, compared to 6-7% in patients with normal renal function 1. This represents the single most important modifiable risk factor in this patient population.

• Patients with CKD experience significantly higher rates of perioperative cardiac complications (myocardial infarction, congestive heart failure, arrhythmias) compared to those without CKD, even when perioperative death rates appear similar 2.
• Mild CKD (creatinine 1.5-2.9 mg/dl) shows no significant increase in stroke or death risk compared to normal renal function, with a 0% incidence in one series 1.
• The 30-day mortality post-CEA increases with worsening renal function: 0.4% for mild CKD, 0.9% for moderate CKD (eGFR 30-59), and 0.9% for severe CKD (eGFR <30) 2.
• Chronic renal failure independently correlates with increased operative mortality (P < 0.001) and increased operative stroke rate (P < 0.0001) 3.

Female Sex

Women undergoing CEA face substantially higher operative risk than men, with a 10.4% complication rate versus 5.8% for men 2.

• In the ACAS and NASCET trials, women had less favorable clinical outcomes in terms of surgical mortality, neurological morbidity, and recurrent carotid stenosis 2.
• Patch angioplasty closure in women materially improves results and should be strongly considered 2.
• However, more recent single-center data from 1998 showed no significant difference in stroke (1.2% women vs 1.7% men) or mortality (0.2% women vs 0.4% men) when modern techniques are employed 4.

Advanced Age

Elderly patients (>75-80 years) demonstrate mixed evidence, with some studies showing higher complication rates while others suggest comparable risks to younger patients when cardiovascular risk factors are few 2.

• The ACST study showed no benefit from CEA in patients ≥80 years of age 2.
• The SPACE trial showed a 5.9% combined stroke and death rate for symptomatic patients <75 years, with rates among those >75 years lower than historical controls, suggesting either improved surgical safety or different cohort characteristics 2.

Diabetes with Chronic Complications

Diabetes with chronic complications significantly increases perioperative risks, while uncomplicated diabetes does not appear to convey higher odds of adverse outcomes 5.

• Diabetic patients with chronic complications undergoing CEA experience increased odds of myocardial infarction (OR 1.12), stroke (OR 1.29), perioperative infection (OR 2.45), mortality (OR 1.48), and longer hospital stay (2.05 additional days) compared to non-diabetic patients 5.
• All cardiac events in one series occurred in diabetic patients, despite constituting only 26% of operations (P = 0.003) 1.
• Diabetes without chronic complications did not independently contribute to increased operative neurologic morbidity or mortality in a large series of 9,795 CEAs 3.

Secondary Risk Factors

Hypertension and Blood Pressure Control

Increasing baseline diastolic blood pressure is an independent predictor of stroke, MI, or death following CEA (RR 1.30 per +10 mmHg increase) 6.

• Severe, difficult-to-control perioperative hypertension was present in two of three patients with severe CKD who suffered postoperative stroke 1.
• Hypertension correlates with increased operative stroke rate (P < 0.05) but not independently with mortality 3.

Cardiac Disease

Cardiac disease independently correlates with both increased operative neurologic morbidity (P < 0.01) and operative mortality (P < 0.0001) 3.

• This is particularly relevant given the high prevalence of cardiac disease in CKD patients.

Symptomatic vs Asymptomatic Disease

Symptomatic patients have higher risk than asymptomatic patients, as do those with hemispheric versus retinal symptoms 2.

• Emergency surgery significantly increases stroke risk (P < 0.0001) 3.
• Advanced neurologic symptoms at time of operation correlate with increased operative stroke rate (P < 0.0001) 3.

Critical Clinical Considerations

Dialysis-Dependent Patients

For patients on dialysis, perioperative risks are prohibitively high even for asymptomatic disease, with 30-day stroke rates of 2.7-5.2%, and poor 3-year survival of 42-46% 2.

• The Society for Vascular Surgery recommends CEA should only be considered in judiciously selected very high-risk symptomatic dialysis patients 2.

Factors NOT Independently Associated with Increased Risk

The following factors did NOT independently contribute to increased operative neurologic morbidity or mortality in large series:

• Age alone (when cardiovascular risk factors are controlled) 3
• Cigarette smoking 3
• Chronic pulmonary disease 3
• Uncomplicated diabetes 3, 5

Procedural Recommendations

For this patient population, CEA should only be performed by surgeons/centers that routinely audit performance with perioperative stroke and death rates <6-7% for symptomatic patients 2.

• Patch angioplasty closure should be strongly considered in female patients 2.
• Careful perioperative blood pressure management is essential, particularly in CKD patients 1, 6.
• CEA is generally more appropriate than carotid stenting for patients over age 70 years 2.