McDermott Katherine M, White Midori, Bose Sanuja, Tan Li Ting, Columbo Jesse A, Siracuse Jeffrey J, Hicks Caitlin W
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD.
Ann Vasc Surg. 2025 Apr;113:370-381. doi: 10.1016/j.avsg.2024.09.036. Epub 2024 Oct 2.
Differential access to new technologies may contribute to racial disparities in surgical outcomes but has not been well-studied in the treatment of carotid artery stenosis. We examined race-based differences in adoption and outcomes of transcarotid artery revascularization (TCAR) among high-risk non-Hispanic (NH) Black and NH white adults undergoing carotid revascularization.
We conducted a retrospective analysis of TCAR, transfemoral carotid artery stenting (TF-CAS), and carotid endarterectomy (CEA) procedures performed for carotid artery stenosis from January 2015 to July 2023 in the Vascular Quality Initiative. NH Black and NH white adults were included if they met Centers for Medicare & Medicaid Services high-risk criteria. Hospitals and physicians were categorized as TCAR-capable if they had previously performed at least one TCAR prior to the time of a given procedure. We fit logistic and linear regressions, adjusted a priori for common demographic, clinical, and disease characteristics, to estimate associations of race with receipt of TCAR (versus CEA or TF-CAS), and to explore associations between race, hospital and physician characteristics, and perioperative composite stroke/death/myocardial infarction.
Of 159,471 high-risk patients undergoing revascularization for carotid artery stenosis (mean age 72 years, 38.5% female, 5.3% NH Black), 28,722 (18.0%) received TCAR, including 16.9% of NH Black adults and 18.1% of NH white adults (P < 0.001). After controlling for patient and disease characteristics, NH Black patients were less likely than NH white patients to receive TCAR (aOR 0.92, 95% CI 0.87-0.99). The use of TCAR did not vary by race among patients treated at TCAR-capable hospitals (aOR 0.98, 95% CI 0.91-1.05) or by TCAR-capable physicians (aOR 1.01, 95% CI 0.93-1.10); however, NH Black race was associated with lower odds of receiving treatment in these settings (TCAR-capable hospital: aOR 0.93 [0.88-0.98]; TCAR-capable physician: aOR 0.92 [0.87-0.98]). NH Black race was associated with higher odds of stroke/death/MI in the full cohort (aOR 1.18, 95% CI 1.03-1.36), but not in the subgroup of patients who received TCAR (aOR 0.87, 95% CI 0.56-1.34).
TCAR attenuated racial disparities in perioperative morbidity and mortality associated with carotid revascularization, but NH Black adults were less likely than NH white adults to receive TCAR. Relatively worse access for NH Black adults to technologically-advanced treatment settings may partially explain the broader persistence of race-based differences in carotid revascularization treatment patterns and outcomes.
新技术的获取差异可能导致手术结果的种族差异，但在颈动脉狭窄治疗方面尚未得到充分研究。我们研究了接受颈动脉血运重建的高危非西班牙裔（NH）黑人和NH白人成年人在经颈动脉血运重建术（TCAR）的采用情况和结果方面基于种族的差异。
我们对2015年1月至2023年7月在血管质量倡议中因颈动脉狭窄而进行的TCAR、经股动脉颈动脉支架置入术（TF-CAS）和颈动脉内膜切除术（CEA）进行了回顾性分析。符合医疗保险和医疗补助服务中心高危标准的NH黑人和NH白人成年人被纳入研究。如果医院和医生在给定手术时间之前至少进行过一次TCAR，则被归类为具备TCAR能力。我们进行了逻辑回归和线性回归，对常见的人口统计学、临床和疾病特征进行了先验调整；以估计种族与接受TCAR（相对于CEA或TF-CAS）之间的关联，并探讨种族、医院和医生特征与围手术期复合性中风/死亡/心肌梗死之间的关联。
在159,471例接受颈动脉狭窄血运重建的高危患者中（平均年龄72岁，38.5%为女性，5.3%为NH黑人），28,722例（18.0%）接受了TCAR，其中NH黑人成年人占16.9%，NH白人成年人占18.1%（P < 0.001）。在控制了患者和疾病特征后，NH黑人患者接受TCAR的可能性低于NH白人患者（调整后比值比[aOR]为0.92，95%置信区间[CI]为0.87 - 0.99）。在具备TCAR能力的医院接受治疗的患者中，TCAR的使用在种族间无差异（aOR为0.98，95% CI为0.91 - 1.05），在具备TCAR能力的医生治疗的患者中也是如此（aOR为1.01，95% CI为0.93 - 1.10）；然而，NH黑人种族在这些情况下接受治疗的几率较低（具备TCAR能力的医院：aOR为0.93[0.88 - 0.98]；具备TCAR能力的医生：aOR为0.92[0.87 - 0.98]）。在整个队列中，NH黑人种族与中风/死亡/心肌梗死的较高几率相关（aOR为1.18，95% CI为1.03 - 1.36），但在接受TCAR的患者亚组中并非如此（aOR为0.87，95% CI为0.56 - 1.34）。
TCAR减轻了与颈动脉血运重建相关的围手术期发病率和死亡率方面的种族差异，但NH黑人成年人接受TCAR的可能性低于NH白人成年人。NH黑人成年人相对更难获得技术先进的治疗环境，这可能部分解释了颈动脉血运重建治疗模式和结果中基于种族的差异为何更广泛地持续存在。
