Thirty-day stroke/mortality of carotid revascularization in asymptomatic patients with newly diagnosed and/or decompensated heart failure exceeds the Society for Vascular Society guideline risks.

Background: According to the latest Society for Vascular Surgery (SVS) guidelines, carotid revascularization for asymptomatic individuals should be offered if the perioperative stroke/death rate does not exceed 3%. Heart failure (HF) has been associated with reduced survival rates following carotid revascularization, which may significantly impact the risk-benefit decision of treating asymptomatic patients with HF. This study aimed to evaluate the 30-day postoperative risks in asymptomatic patients with newly diagnosed and/or decompensated HF undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS).

Methods: Asymptomatic patients who underwent CEA and CAS were identified in the ACS-NSQIP targeted databases from 2011-2023. HF was defined as newly diagnosed HF and/or an acute exacerbation of chronic HF within 30 days of the surgery A 1:3 propensity-score matching was used to balance preoperative differences between HF and non-HF patients. Patients who underwent CEA and CAS were analyzed separately. Thirty-day postoperative outcomes were examined.

Results: There were 23,274 patients who underwent CEA, where 601 (2.58%) had HF, who were matched to 1,803 non-HF patients. Among 1,361 patients who underwent CAS, 87 (6.38%) had HF and were matched to 222 non-HF counterparts. HF patients had a much higher comorbidity burden. After CEA, HF patients had higher risks of stroke/mortality (4.83% vs 2.55%, p=0.01), cardiac (6.66% vs 3.38%, p<0.01), pulmonary (4.49% vs 2.44%, p=0.02), and renal complications (1.66% vs 0.44%, p=0.01), as well as sepsis (1.50% vs 0.44%, p=0.02), distal embolization (0.50% vs 0.00%, p=0.02), unplanned operation (5.99% vs 3.49%, p=0.01), prolonged hospital stay (p<0.01), and 30-day readmission (13.14% vs 8.65%, p<0.01). After CAS, HF patients had similarly high risks of stroke/mortality (5.75% vs. 3.60%, p=0.53).

Conclusion: For newly diagnosed and/or decompensated HF patients with asymptomatic carotid stenosis, the 30-day postoperative stroke/mortality risks after both CEA and CAS greatly exceed the SVS guideline recommendations. Coupled with the substantially higher risk of other major complications, the decision to pursue surgical revascularization in asymptomatic patients with HF should be approached with extreme caution, and conservative management may be prioritized.