Carotid Artery Intervention May Still Be Justified in Asymptomatic Patients with End-Stage Renal Disease

Background While carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce the long-term risk of stroke, patients with a short life expectancy or multiple medical comorbidities, including end-stage renal disease (ESRD), may not derive significant benefit from these interventions. The benefits of intervention are especially questionable for patients with asymptomatic carotid artery disease. We assessed the outcomes of stroke and mortality following carotid intervention in a real-world ESRD population. Methods This multicenter retrospective cohort study utilized the TriNetX US Collaborative Network, a global federated database, to identify individuals with and without ESRD who underwent CEA or CAS for asymptomatic carotid artery disease between January 2014 and August 2024. Patients were 1:1 propensity score matched based on preoperative covariates, including demographics, comorbidities, and medications. Thirty-day, 3-year, and 5-year rates of stroke and all-cause mortality were compared between the 2 cohorts, using odds ratios (ORs) with 95% confidence intervals (CIs). Results This study identified 332 ESRD patients and 28,369 non-ESRD patients who underwent carotid intervention for asymptomatic carotid artery disease. Propensity-score matching yielded 329 patients. 53.0% were male with a mean age of 67.3 ± 8.7 years. The mean follow-up was 958 days. Outcomes at 30 days resulted in comparable rates for stroke and mortality. At 3 years, patients with ESRD had greater rates of stroke (15.8% vs. 10.0%; OR, 1.65; 95% CI, 1.05–2.61). Mortality was significantly higher in the ESRD group at both 3 years (23.5% vs. 11.8%; OR, 2.31; 95% CI, 1.51–3.53) and 5 years (32.2% vs. 15.5%; OR, 2.59; 95% CI, 1.78–3.78). Subgroup analysis comparing CEA versus CAS demonstrated similar stroke rates at all time points. Notably, the 5-year stroke rate was 19.4% for CEA versus 14.0% for CAS ( P = 0.33). Mortality was comparable at all time points, with 5-year rates of 33.3% for CEA versus 30.1% for CAS ( P = 0.64). Conclusion ESRD patients exhibited nearly 2-fold long-term mortality after carotid intervention compared with non-ESRD patients, whereas neurologic outcomes remained comparable. Within ESRD patients, long-term neurologic complications and mortality remained statistically similar. This study highlights the poor prognosis of ESRD patients undergoing carotid intervention. Carotid intervention remains a reasonable option for selected ESRD patients, particularly those with a lower comorbidity burden.