Sex differences in the outcomes after carotid revascularization in real-world experience

Objective: To analyze the impact of sex on the occurrence of death, stroke and myocardial infarction at 30 days and at 1 year after either carotid endarterectomy (CEA) or carotid artery stenting (CAS) for the treatment of significant carotid stenosis on the real-world dataset coming from TriNetX. Methods: A retrospective multicenter cohort study was built within the TriNetX platform (TriNetX LLC, Cambridge, MA) to investigate cohorts of patients aged 18 years or older diagnosed with carotid artery occlusion or stenosis receiving either CEA or CAS from 1 January 2010 to 19 June 2025. Patients were also classified as symptomatic, thus delineating four cohorts: symptomatic CAS, symptomatic CEA, asymptomatic CAS and asymptomatic CEA. The primary outcome was identified as the occurrence of death from all causes, stroke and myocardial infarction, within each of the four cohorts of patients, comparing male versus female patients. These outcomes were evaluated both individually and as a composite outcome within 1 month and 1 year after the intervention. Results: Results of 59340 procedures of carotid revascularization (5599 CAS and 53741 CEA) from 2010 ongoing were analyzed, being 22574 on female patients (38.0%). At 30 days, the propensity-matched score analysis adjusted for age did not show any significant difference for the risk of all the outcomes between males and females both in the cohort of patients who underwent CEA as well as in that of patients who underwent CAS, neither in symptomatic nor in asymptomatic patients. At one year, no significant differences were recorded between men and women for the all the outcomes in both the cohorts, except for a lower survival of symptomatic female patients who underwent CAS (86.7% vs. 93.8%, p=0.013). Conclusions: At 30 days and at long-term follow-up no differences were recorded between male and female patients undergoing CAS or CEA, except for a lower 1-year survival of symptomatic female patients who underwent CAS.