Safety of carotid artery revascularization procedures in patients with atrial fibrillation.
BACKGROUND
Atrial fibrillation (Afib) is a major contributor to cerebrovascular events. Coexisting carotid artery disease is not uncommon in Afib patients, yet they have been excluded from major randomized clinical trials. Therefore, the aim of this study was to evaluate the safety of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in Afib patients.


METHODS
The Premier Healthcare Database was queried (2009-2015). Patients who underwent CEA or CAS were captured by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multivariable logistic modeling was implemented to examine the outcomes: in-hospital stroke, intracerebral hemorrhage (ICH), mortality, and stroke/death.


RESULTS
There were 86,778 patients included. The majority were asymptomatic (n = 82,128 [94.6%]). Afib was reported in 6743 patients (7.8%). In terms of absolute outcomes in both asymptomatic and symptomatic patients, Afib patients (vs non-Afib patients) had higher mortality and stroke/death (asymptomatic: mortality, 0.4% vs 0.2%; stroke/death, 1.7% vs 1.2%; symptomatic: mortality, 6.9% vs 2.1%; stroke/death, 10.6% vs 4.5%; all P < .05). Adjusted analysis yielded higher odds of ICH (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.00-1.67), mortality (aOR, 1.59; 95% CI, 1.11-2.26), and stroke/death (aOR, 1.30; 95% CI, 1.08-1.58) in Afib patients. Although univariable analysis found Afib to be a statistically significant predictor of ischemic stroke, similar results could not be elucidated in the multivariable analysis (aOR, 1.17; 95% CI, 0.93-1.47). In Afib patients, important predictors of stroke/death included CAS (aOR, 1.80; 95% CI, 1.21-2.68) and symptomatic presentation (aOR, 5.00; 95% CI, 3.20-7.83). Other important predictors were type of preoperative medication use, age, and hospital size.


CONCLUSIONS
Afib was associated with worse postoperative outcomes in patients with carotid artery disease. Symptomatic status in Afib patients is associated with a stroke/death risk that is higher than in recommended guidelines for CEA and particularly for CAS. Overall, CEA was associated with lower periprocedural ICH, mortality, and stroke/death in Afib patients compared with CAS.
['Nejim|Besma|B|', 'Mathlouthi|Asma|A|', 'Weaver|Libby|L|', 'Faateh|Muhammad|M|', 'Arhuidese|Isibor|I|', 'Malas|Mahmoud B|MB|']
D000368:Aged D000369:Aged, 80 and over D001281:Atrial Fibrillation D002340:Carotid Artery Diseases D002543:Cerebral Hemorrhage D003430:Cross-Sectional Studies D016208:Databases, Factual D016894:Endarterectomy, Carotid D057510:Endovascular Procedures D005260:Female D017052:Hospital Mortality D006801:Humans D008297:Male D008875:Middle Aged D012189:Retrospective Studies D018570:Risk Assessment D012307:Risk Factors D015607:Stents D020521:Stroke D013997:Time Factors D016896:Treatment Outcome D014481:United States
Atrial fibrillation Carotid artery disease Carotid endarterectomy Carotid revascularization Carotid stenting