Carotid artery stenting has increased rates of post-procedure stroke, death and resource utilization than carotid endarterectomy in the US

Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter (Impact Factor: 3.02). 10/2008; 48(6):1442-50, 1450.e1. DOI: 10.1016/j.jvs.2008.07.017
Source: PubMed


Carotid endarterectomy (CEA) remains the procedure of choice for treatment of patients with severe carotid artery stenosis. The role of carotid artery stenting (CAS) in this patient group is still being defined. Prior single and multicenter studies have demonstrated economic savings associated with CEA compared with CAS. The purpose of this study was to compare surgical outcomes and resource utilization associated with these two procedures at the national level in 2005, the first year in which a specific ICD-9 procedure code for CAS was available.
All patient discharges for carotid revascularization for the year 2005 were identified in the Nationwide Inpatient Sample based on ICD9-CM procedure codes for CEA (38.12) and CAS (00.63). The primary outcome measures of interest were in-hospital mortality and postoperative stroke; secondary outcome measures included total hospital charges and length of stay (LOS). All statistical analyses were performed using SAS version 9.1 (Cary, NC), and data are weighted according to the Nationwide Inpatient Sample (NIS) design to draw national estimates. Univariate analyses of categorical variables were performed using Rao-Scott chi(2), and continuous variables were analyzed by survey weighted analysis of variance (ANOVA). Multivariate logistic regression was performed to evaluate independent predictors of postoperative stroke and mortality.
During 2005, an estimated 135,701 patients underwent either CEA or CAS nationally. Overall, 91% of patients underwent CEA. The mean age overall was 71 years. Postoperative stroke rates were increased for CAS compared with CEA (1.8% vs 1.1%, P < .05), odds ratio (OR) 1.7; (95% confidence interval [CI] 1.2-2.3). Overall, mortality rates were higher for CAS compared with CEA (1.1% vs 0.57%, P < .05) this difference was substantially increased in regard to patients with symptomatic disease (4.6% vs 1.4%, P < .05). By logistic regression, CAS trended toward increased mortality, OR 1.5; (95% CI .96-2.5). Overall, the median total hospital charges for patients that underwent CAS were significantly greater than those that underwent CEA ($30,396 vs $17,658 P < .05).
Based on a large representative sample during the year 2005, CEA was performed with significantly lower in-hospital mortality, postoperative stroke rates, and lower median total hospital charges than CAS in US hospitals. As the role for CAS becomes defined for the management of patients with carotid artery stenosis, clinical as well as economic outcomes must be continually evaluated.

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    ABSTRACT: Although there is level I evidence supporting the role of carotid endarterectomy (CEA) in patients with asymptomatic disease, opinion remains polarised regarding what constitutes optimal management, especially as carotid artery stenting (CAS) has emerged as a less invasive alternative. Reasons for this lack of consensus amongst surgeons, interventionists, neurologists and stroke physicians include our continued inability to identify 'high risk for stroke' patients in whom to target costly therapies. For example, recent data from the USA suggest that up to $21 billion is being spent each year on ultimately 'unnecessary' interventions. Second, is growing evidence that improvements in what now constitutes modern 'best medical therapy' has significantly reduced the risk of stroke compared to that observed in ACAS and ACST. If true, this will compromise risk:benefit analyses used in national and international guidelines. At a time when evidence suggests that up to 94% of interventions may not benefit the patient, the authors urge that at least one of the randomised trials comparing CEA with CAS in asymptomatic patients includes an adequately powered third limb for BMT. Timely investment now could optimise patient care and resource utilisation for all of us in the future.
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