Long-term risk of major adverse cardiovascular events after carotid endarterectomy—a 9-year prospective cohort study of the Athero-Express biobank

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INTRODUCTION: Carotid endarterectomy (CEA) is performed to lower the long-term risk of stroke in patients with carotid stenosis. Data evaluating long-term outcomes after CEA are scarce, but crucial for accurately determining long-term benefits. We aimed to estimate the long-term risk of major adverse cardiovascular and cerebrovascular events (MACE) after CEA. PATIENTS AND METHODS: A data linkage study was performed using patients from the Athero-Express biobank study who underwent CEA in two Dutch tertiary referral hospitals between 2002 and 2020. Data were linked to the Cause of Death Register, Population Register from Statistics Netherlands and the Hospital Discharge Register. The primary outcome was the occurrence of MACE at any time during follow-up and in the postprocedural (beyond 30 days) period. RESULTS: CEA was performed in 2123 unique patients; linkage was possible for 1876. Median age was 70 years, 70% was male, and 87% had a symptomatic stenosis. MACE occurred in 455 patients (24.3%) during 9.2 years median follow-up. Five and 10-year cumulative incidence of MACE was 14.3% and 26.4%, respectively. Vascular death was the predominant contributor to MACE with 246 events (54.1%). Older age, current smoking, lower estimated glomerular filtration rate, diabetes mellitus and coronary artery disease (CAD) were associated with an increased risk of MACE. Preoperative antiplatelet use was associated with decreased risk of MACE. Patients with ischaemic stroke as qualifying event were at higher risk of MACE (P = .018). The incidence rate of MACE did not change over time (P = .9). DISCUSSION: Patients remain at high risk of MACE after CEA, especially of vascular death and in older patients, current smokers and patients with diabetes or CAD. CONCLUSION: These findings underscore the need to enhance cardiovascular preventive strategies following CEA, in order to optimise long-term benefit.

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