Carotid endarterectomy versus stenting in patients with carotid artery stenosis and type 2 diabetes: a nationwide cohort study from the USA.

Objectives: Patients with type 2 diabetes mellitus (T2DM) are associated with a higher risk of carotid artery stenosis and adverse postoperative outcomes compared with individuals without T2DM. The comparative effectiveness after carotid endarterectomy (CEA) versus carotid artery stenting (CAS) in this population remains unclear. This study aimed to compare the in-hospital outcomes of CEA versus CAS in patients with carotid artery stenosis and T2DM. Design: A retrospective cohort study using a doubly robust estimation model which incorporated an inverse probability weighting (IPW) model, followed by logistic regression to balance baseline characteristics. Setting: Nation-wide administrative hospitalizations in the US National Inpatient Sample, 2016-2021. Participants: Adults (≥18 years) with T2DM who underwent either CEA or CAS for asymptomatic or symptomatic carotid stenosis. Main outcome measures: In-hospital mortality, postoperative stroke and myocardial infarction during the same admission. Results: A total of 31,363 patients with asymptomatic carotid stenosis (CAS, n=6338; CEA, n=25,025) and 3710 patients with symptomatic carotid stenosis (CAS, n=1271; CEA, n=2439) were evaluated. Among asymptomatic patients, the CEA group had a lower risk of mortality (108 (0.4%) vs 58 (0.9%); adjusted OR 0.997, 95% CI 0.995 to 0.999) but a higher incidence of myocardial infarction (500 (2.0%) vs 151 (2.4%); adjusted OR (aOR) 1.005, 95% CI 1.001 to 1.008) compared with the CAS group. No significant difference in the incidence of postoperative stroke was observed. Among symptomatic patients, the CEA group was also associated with a lower risk of mortality (29 (1.2%) vs 56 (4.4%); aOR 0.973, 95% CI 0.961 to 0.985), with no significant differences in postoperative stroke or myocardial infarction. Conclusions: CEA was associated with lower in-hospital mortality in type 2 diabetic patients with symptomatic or asymptomatic carotid stenosis compared with CAS, but its use in asymptomatic individuals should be carefully considered due to potential cardiovascular risks.