Impact of Metabolic Syndrome on Short-Term Outcome of Carotid Revascularization: A Large Sample Size Study in Chinese Population
Introduction
Carotid artery stenosis is a significant contributor to ischemic stroke, accounting for 15%-20% of cases. Carotid revascularization through carotid endarterectomy (CEA) or carotid artery stenting (CAS) remains pivotal in managing symptomatic and high-grade asymptomatic stenosis. While CEA is the gold standard, CAS has emerged as a less invasive alternative with comparable efficacy. Metabolic syndrome (MetS), characterized by obesity, hypertension, dyslipidemia, and insulin resistance, is a global health concern linked to cardiovascular morbidity and arterial stiffness. Despite its established role in atherosclerosis, the relationship between MetS and perioperative outcomes after carotid revascularization remains understudied, particularly in Asian populations. This study investigates the prevalence of MetS in Chinese patients undergoing CEA or CAS and evaluates its impact on 30-day major adverse clinical events (MACEs).
Methods
Study Design and Population
This single-center retrospective analysis included 2,068 patients (766 CEA, 1,302 CAS) treated at Xuanwu Hospital, Beijing, between January 2013 and December 2017. Inclusion criteria involved symptomatic stenosis ≥50% or asymptomatic stenosis ≥70%, confirmed by digital subtraction angiography (DSA). Exclusions were applied for incomplete data or lost follow-up.
Metabolic Syndrome Definition
MetS was defined as ≥3 of the following:
- Hypertension: Systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg.
- Low HDL: <40 mg/dL (men) or <50 mg/dL (women).
- Elevated triglycerides (TG): ≥150 mg/dL.
- Elevated fasting blood glucose (FBG): ≥110 mg/dL.
- Obesity: Body mass index (BMI) ≥30 kg/m².
Surgical and Endovascular Procedures
- CEA: Performed under general anesthesia with transcranial Doppler monitoring. Techniques (standard/eversion, shunt use) were surgeon-dependent.
- CAS: Conducted under local anesthesia with routine embolic protection devices (EPDs). Stent selection and procedural details were based on operator experience.
Outcome Measures
The primary endpoint was 30-day MACEs, encompassing death, stroke (major/minor), and myocardial infarction (MI). Stroke was defined as neurological deficits lasting >24 hours; MI required ECG changes or elevated cardiac enzymes.
Statistical Analysis
Univariate comparisons (χ², Fisher’s exact, t-tests) identified risk factors, followed by multivariate logistic regression to determine independent predictors. Analyses were stratified by CEA and CAS cohorts.
Results
Baseline Characteristics and MetS Prevalence
The cohort had a mean age of 64.7 years, 83.7% male, and 61.2% symptomatic. MetS prevalence was 17.9% (370/2,068), increasing annually (Figure 2). Components like low HDL and elevated FBG showed marked upward trends (Figure 3).
Short-Term Outcomes
Overall 30-day MACEs occurred in 3.4% (26/766) of CEA and 3.1% (40/1,302) of CAS patients (P = 0.687).
- CEA: Higher rates of major stroke (2.0% vs. 0.9%; P = 0.045) and MI (0.9% vs. 0.2%; P = 0.028).
- CAS: More minor strokes (2.0% vs. 0.5%; P = 0.007).
Risk Factor Analysis
CEA Cohort
Univariate analysis associated MACEs with diabetes (53.8% vs. 30.9%; P = 0.014) and MetS (34.6% vs. 15.8%; P = 0.023). Multivariate regression confirmed diabetes (OR = 2.35, 95% CI: 1.06–5.21; P = 0.036) and MetS (OR = 2.48, 95% CI: 1.07–5.76; P = 0.035) as independent predictors.
CAS Cohort
MACEs correlated with coronary artery disease (CAD: 40.0% vs. 21.6%; P = 0.006), internal carotid artery (ICA) tortuosity (67.5% vs. 37.6%; P < 0.001), and higher SBP (143.4 vs. 135.4 mmHg; P = 0.004). Multivariate analysis identified SBP (OR = 1.02 per mmHg, 95% CI: 1.01–1.04; P = 0.010), CAD (OR = 2.38, 95% CI: 1.24–4.59; P = 0.009), and ICA tortuosity (OR = 3.22, 95% CI: 1.64–6.34; P = 0.001) as significant predictors.
Discussion
Temporal Trends in MetS Components
The rising prevalence of MetS (17.9% overall) aligns with global trends driven by dietary and lifestyle changes. Notably, dyslipidemia (low HDL) and hyperglycemia increased disproportionately, reflecting systemic metabolic dysregulation in this population. These findings underscore the need for aggressive risk factor modification in carotid disease management.
Differential Impact of MetS on CEA vs. CAS
MetS independently predicted MACEs after CEA but not CAS. This discrepancy may stem from differences in procedural stress: CEA under general anesthesia may exacerbate metabolic derangements, whereas CAS under local anesthesia minimizes systemic perturbations. Diabetes, a core MetS component, likely contributes to microvascular dysfunction and perioperative instability.
For CAS, anatomical (ICA tortuosity) and hemodynamic (elevated SBP) factors dominated risk. ICA tortuosity complicates device navigation, increasing embolic risk, while hypertension may destabilize vulnerable plaques. CAD’s association with CAS outcomes highlights shared atherosclerotic pathways affecting both coronary and cerebrovascular beds.
Clinical Implications
- CEA: Preoperative optimization of glycemic control and MetS components may reduce complications.
- CAS: Emphasis on blood pressure management and anatomical assessment (e.g., ICA tortuosity) is critical.
Limitations
This retrospective study lacks long-term follow-up and generalizability to non-Chinese populations. MetS criteria excluded LDL and total cholesterol, potentially underestimating dyslipidemia’s role.
Conclusion
Metabolic syndrome prevalence is rising among Chinese patients undergoing carotid revascularization. MetS independently increases 30-day MACEs after CEA but not CAS, underscoring procedure-specific risk profiles. Diabetes and hypertension remain critical modifiable factors, while anatomical challenges in CAS warrant tailored preoperative planning. These findings advocate for personalized risk stratification and multidisciplinary management in carotid revascularization.
doi.org/10.1097/CM9.0000000000001038
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