RS34 - Achieving a textbook outcome is associated with improved 5-year survival for female patients undergoing carotid revascularization in the vascular quality initiative

Objectives: Carotid revascularization for asymptomatic disease is known to have disparate outcomes based on patient sex, with historical data from the asymptomatic carotid atherosclerosis study (ACAS) demonstrating that females may not derive as great a stroke risk reduction versus males. Textbook outcomes(TO) are an emerging quality metric representing the ideal surgical outcome, and here we sought to determine whether TOs have an impact on sex disparities in early and late outcomes for carotid endarterectomy(CEA), transcarotid artery revascularization(TCAR), and transfemoral carotid artery stenting(tfCAS).

Methods: The Vascular Quality Initiative(VQI) CEA and carotid stenting databases were queried for elective cases performed for asymptomatic disease from January 2016-October 2024. TO was defined as freedom from postoperative neurologic event, myocardial infarction, reperfusion syndrome, cranial nerve injury, reoperation, 30-day mortality, length of stay>1 day, and non-home discharge. CEA, TCAR, and tfCAS cohorts, stratified by sex and TO, were analyzed using the Kaplan Meier method for survival and logistic regression for factors associated with a non-TO.

Results: Males had higher TO rates than women for CEA(76.8% vs 72.5%), TCAR(77.8% vs 72.9%), and tfCAS(81.3% vs 75.8%, all p< 0.001). Characteristics common to non-TO females included greater incidence of chronic obstructive pulmonary disease, extreme body mass index (BMI)( < 20/>40 kg/m2), and chronic kidney disease compared to non-TO males(all, p< 0.001). Non-TO female patients were less often taking a statin preoperatively for CEA(83.4% vs 86.0%, p< 0.001) and TCAR(87.8% vs 91.4%, p< 0.001) versus non-TO male patients. TO males had lower survival at 5-years compared to TO females for CEA(94.3% vs 95.3%, p< 0.001)(Figure 1) and tfCAS(92.3% vs 94.3%, p=0.002)(Figure 2). 5-year survival was similar for females and males undergoing TCAR. Non-TO males had lower 5-year survival compared to non-TO females undergoing CEA(89.5% vs 91.1%, p< 0.001)(Figure 1). Multivariable logistic regression examining risk factors for a non-TO demonstrated that, across all procedures, annual center volume-outcome relationship was not as strong for females as it was for males. For CEA, females from urban settings were more likely to achieve a non-TO(OR 1.15, 95%CI 1.07-1.23, p< 0.001). For TCAR, females with extreme BMIs were at risk for a non-TO(OR 1.20, 95% CI1.04-1.38, p=0.01).

Conclusions: While a greater proportion of males achieve TO compared to females undergoing carotid revascularization procedures as a whole, when TO is achieved, females demonstrate better 5-year survival after CEA and tfCAS despite similar perioperative outcomes. Thus, TOs represent an important quality metric that may help address sex disparities in carotid revascularization.