Carotid Endarterectomy Performed in Asymptomatic Females is Not Associated With Increased Perioperative and Long-term Complication Rates in Comparison with Males

The aim of this study was to retrospectively compare early and long-term results of carotid enadarterectomy performed in patients with severe asymptomatic carotid artery stenosis, stratifying patients by gender, in the experience of a high-volume teaching hospital. Between January 2009 and December 2020, 2821 consecutive carotid enadarterectomies were performed. The data concerning these operations were entered prospectively in a dedicated database, covering the main pre-, intra-, and postoperative variables. A retrospective analysis of this database was performed, and 2194 operations performed in asymptomatic patients were identified, 758 performed in female patients (group F) and 1436 performed in male patients (group M). Perioperative outcomes were analyzed in terms of mortality, major neurological events, and major complications. The results between the two groups were compared using χ2 tests. Uni and multivariate analysis (binary logistic regression) was performed to identify factors significantly associated with the risk of stroke and death at 30 days in the entire study group. Follow-up results were analyzed by life-table analysis and Kaplan-Meier curves in terms of survival, stroke-free survival, absence of neurological symptoms, and absence of significant restenosis. The comparison between the two groups was performed by log-rank test. There was no difference between the two groups in terms of preoperative baseline characteristics, anatomical status, and intraoperative details, except for a significantly higher shunt insertion rate among females. At 30 days, the rate of stroke and death was 0.4% in the F group and 1% in the M group (P = .1). The combined outcome of stroke, death, acute myocardial infarction, and local and systemic complications in the perioperative period was 4.8% in the F group and 5.9% in the M group (P = .2). At multivariate analysis, intervention performed in combination with myocardial revascularization was a factor independently associated with a significant increase in perioperative risk in the entire study group, whereas, surprisingly, female sex was protective towards the occurrence of such an outcome (P = .05; hazard ratio, 0.2; 95% confidence interval, 0.04-0-9). The average duration of follow-up was 32 ± 29 months (range, 1-132 months); overall, follow-up covered 90.5% of the study group (1943 patients). There were no differences between the two groups in terms of estimated 10-year survival, stroke-free survival, absence of neurological symptoms, and absence of significant (>70%) restenosis rates. Female sex per se is not a risk factor for adverse outcomes in the early and long-term setting after carotid surgery in asymptomatic patients; indeed, it seems that in the perioperative period it may even be protective.