June 27, 2026

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

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Carotid stenosis (n=1876). Intervention: Carotid endarterectomy. Primary outcome: Occurrence of major adverse cardiovascular and cerebrovascular events (MACE) at any time during follow-up and in the postprocedural (beyond 30 days) period.

Key Result

Following carotid endarterectomy, patients experienced a 24.3% incidence of major adverse cardiovascular and cerebrovascular events over a median 9.2-year follow-up, predominantly vascular death.

Key Points

This study aims to estimate the long-term risk of major adverse cardiovascular events following carotid endarterectomy.
Data linkage study of patients from the Athero-Express biobank who underwent carotid endarterectomy.
Follow-up from 2002 to 2020, with a median follow-up of 9.2 years for 1876 patients.
Primary outcome was the occurrence of major adverse cardiovascular events during the entire follow-up and postprocedural period.
MACE occurred in 455 patients (24.3%) during follow-up, with 5-year and 10-year cumulative incidence rates of 14.3% and 26.4%.
Vascular death contributed to 54.1% of MACE, and older age, current smoking, lower kidney function, diabetes, and CAD increased risk.
Preoperative antiplatelet use was linked to a lower risk of MACE, and risk was notably higher in patients with ischaemic stroke as the qualifying event (P = .018).

Study Design

Type

Cohort (n=1,876)

Multicenter

Yes

Structured PICO

Population

1,876 patients who underwent carotid endarterectomy (median age 70, 30% female, 87% symptomatic stenosis), followed for a median of 9.2 years.

Exposure

Carotid endarterectomy (CEA)

Outcome

Occurrence of major adverse cardiovascular and cerebrovascular events (MACE) at any time during follow-up and in the postprocedural (beyond 30 days) periodcomposite

Abstract

Abstract 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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