I guess you'll have to ask your doctor why the fuck you need stenting or endarterectomy with the risks they entail. Did your doctor tell you of those risks?
Carotid Interventions for Women: The Hazards and Benefits
Abstract
The goal of the current review is to examine the hazards and benefits of carotid interventions in women and to provide recommendations for the indications for carotid intervention in female patients. Stroke and cerebrovascular disease are prevalent in women. There are inherent biological and other differences in men and women, which affect the manifestations and outcome of stroke, with women experiencing worse disability and higher mortality following ischemic stroke than men. Due to the underrepresentation of female patients in most clinical trials, the ability to make firm but alternative recommendations for women specifically on the management of carotid stenosis is challenging. Although some data suggest that women might have worse periprocedural outcomes as compared to men following all carotid revascularization procedures, there is also an abundance of data to support a similar risk for carotid procedures in men and women, especially with carotid endarterectomy and transcarotid artery revascularization. Therefore, the indications for carotid revascularization are the same in women as they are in men. The choice of a carotid revascularization procedure in women is based upon the same factors as in men and requires careful evaluation of a particular patient’s risk profile, anatomic criteria, plaque morphology, and medical comorbidities that might favor one technique over the other. When performing carotid revascularization procedures in women, tailored techniques and procedures to address the small diameter of the female artery are warranted.
The study of sex differences on stroke incidence, prevalence, and mortality is an emerging field of stroke epidemiology and care.1 The GBD Study (Global Burden of Disease) 2016 estimated that the global lifetime risk of stroke among men (24.7%; 95% uncertainty interval, 23.3–26.0) was not significantly different from that among women (25.1%; 95% uncertainty interval, 23.7–26.5); however, there were regional and between-country differences in sex-specific risk.2 Nevertheless, due to the increasing stroke risk with age and a longer life expectancy, women experience more strokes and more death from stroke over their lifetime.3,4
Additionally, women are reported to have worse functional outcomes after stroke, adding to the negative impact of stroke on women.4 One of the major treatable causes of ischemic stroke and transient ischemic attack is atherosclerotic carotid artery disease which accounts for at least 10% to 15% of cases, depending on the method of etiological classification and the patient population studied.5 The prevalence of atherosclerotic carotid disease increases with age and is higher in men than in women. In White populations, ≥50% stenosis of the carotid artery was identified in 2.3% of men in the sixth decade, in 6.0% in the seventh decade, and 7.5% of men aged 80 years; in women, the corresponding prevalence figures were 2.0%, 3.6%, and 5.0% in these age groups, respectively.6 The estimated prevalence of increased carotid intima-media thickness, carotid plaque, and carotid stenosis by sex are shown in Table 1.7 Age-related changes in vascular function in both sexes include endothelial dysfunction and arterial stiffness, accompanied by increasing systolic BP and pulse pressure.8 Current smoking, diabetes, and hypertension are common risk factors associated with increased carotid intima-media thickness and carotid plaque.9 These age-related changes progress faster in women than men after the sixth decade of life. Postmenopausal women have stiffer arteries than their male counterparts, which is consistent with higher rates of hypertension in women than men after the age of 65 years.10
| Men (30–79 y) | Women (30–79 y) | |
|---|---|---|
| Increased carotid intima-media thickness | 32.1% (20.2–46.7) | 23.2% (13.7–35.9) |
| Carotid plaque | 25.2% (16.1–36.7) | 17.1% (10.4–26.5) |
| Carotid stenosis | 1.8% (1.3–2.6) | 1.2% (0.8–1.6) |
Cardiovascular risk factors facilitate the development and growth of atherosclerotic plaque. Still, it is not yet fully understood precisely which risk factors predispose toward plaque destabilization by accelerating plaque growth with consequent rupture and thrombosis.11 Women with metabolic syndrome and hypertriglyceridemia are reported to have an odds ratio of 3.01 (95% CI, 0.25–36.30) to develop unstable plaques.12 Moreover, data from the Oxford Vascular Study reported that the 5-year ipsilateral stroke risk increased with the degree of stenosis; patients with 70% to 99% stenosis had a significantly greater 5-year ipsilateral stroke risk than did those with 50% to 69% stenosis, and patients with 80% to 99% stenosis had a significantly greater 5-year ipsilateral stroke risk than did those with 50% to 79% stenosis. Stroke risk was linearly associated with the degree of ipsilateral stenosis (P<0.0001). These results were independent of sex.9
However, the outcomes related to stroke and carotid disease are worse in women due to many factors, including disease pathophysiology, access to care, provider bias, and socioeconomic status. There are likely biological differences that may explain the different manifestations of similar diseases in men and women, and the role of estrogen and other sex hormones likely plays a significant role in this regard.13 The mechanisms of the cerebral ischemic response may be different in female and male cells.14 Women with cerebrovascular disease may be less likely to be managed with appropriate medical therapies compared to men.13 Behavioral issues have been noted in the literature: women are less likely than men to call for an ambulance when they experience a stroke, possibly precluding the use of thrombolytic therapies.15 Finally, the clinical manifestations of stroke may differ between the sexes.13 Women more frequently present with nonconventional stroke symptoms, including incontinence, nausea, and loss of consciousness, and difficulty swallowing.13,16,17
With these issues in mind, the goal of the current review is to examine the hazards and benefits of carotid interventions in women and to provide recommendations for the indications for carotid intervention in female patients.
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