BACKGROUND: The Society for Vascular Surgery guidelines recommend carotid revascularization within 14 days of symptom onset for neurologically stable stroke patients. However, in the United States, insurance status may affect surgical timing, although large-scale studies are lacking. Using the Vascular Quality Initiative database, we evaluated the impact of insurance status on surgical wait times for patients with symptomatic carotid disease. METHODS: Symptomatic patients undergoing carotid revascularization from 2010 to 2022 with Modified Rankin score <
2 were included. The primary outcome was time from symptom onset to intervention, with patients divided into timely or late cohort (LC) intervention groups (>
14 days). Categorical variables were compared using Chi-square test, and 1-way analysis of variance was used for continuous variables. Multivariable logistic regression assessed the association between insurance status and surgical wait time, adjusting for confounders. RESULTS: There were 11,973 timely cohort and 21,253 LC patients. LC patients were older, less likely to undergo carotid endarterectomy, and more likely to have elective procedures. After adjusting for confounders, Medicare Advantage (adjusted odds ratio [aOR] 0.89, 95% confidence interval [CI] 0.80-0.99, P = 0.03), Commercial (aOR 0.84, 95% CI 0.78-0.90, P <
0.001), Military/Veterans Affairs (aOR 0.67, 95% CI 0.54-0.84, P <
0.001), and Self-Pay (aOR 0.54, 95% CI 0.45-0.65, P <
0.001) had lower odds of delayed carotid endarterectomy/carotid artery stenting compared to Medicare. Medicaid patients had similar odds to Medicare. Non-US insurance had higher odds (aOR 1.48, 95% CI 1.13-1.95, P = 0.005) compared to Medicare. CONCLUSIONS: Medicare, Medicaid, and non-US insurance patients were more likely to experience surgical delays compared to those with Commercial, Military/Veterans Affairs, and Self-Pay coverage. Further research is needed to explore the causes and impacts of these delays.