Carotid endarterectomy was performed with lower stroke and death rates than carotid artery stenting in the United States in 2003 and 2004

Department of Surgery, University of Massachusetts Medical School, Worcester, MA 01655, USA.
Journal of Vascular Surgery (Impact Factor: 3.02). 01/2008; 46(6):1112-1118. DOI: 10.1016/j.jvs.2007.08.030
Source: PubMed


Although carotid endarterectomy (CEA) is the gold standard for the treatment of carotid artery stenosis, the recent United States Food and Drug Administration approval of carotid artery stenting (CAS) may have led to its widespread use outside of clinical trials and registries. This study compared in-hospital postoperative stroke and mortality rates after CAS and CEA at the national level.
The Nationwide Inpatient Sample (NIS) was queried to identify all patient-discharges that occurred for revascularization of carotid artery stenosis. The International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for CEA (38.12), CAS (00.63), and insertion of noncoronary stents (39.50, 39.90) were used in conjunction with the diagnostic codes for carotid artery stenosis, with (433.11) and without (433.10) stroke. Primary outcome measures included in-hospital postoperative stroke and death rates. Multivariate logistic regressions were performed to evaluate independent predictors of postoperative stroke and mortality. Adjustment was made for age, sex, medical comorbidities, admission diagnosis, procedure type, year, and hospital type.
During the calendar years 2003 and 2004, an estimated 259,080 carotid revascularization procedures were performed in the United States. CAS had a higher rate of in-hospital postoperative stroke (2.1% vs 0.88%, P < .0001) and higher postoperative mortality (1.3% vs 0.39%) than CEA. For asymptomatic patients (92%), the postoperative stroke rate was significantly higher for CAS than CEA (1.8% vs 0.86%, P < .0001), but the mortality rate was similar (0.44% vs 0.36%, P = .36). For symptomatic patients (8%), the rates for postoperative stroke (4.2% vs 1.1%, P < .0001) and mortality (7.5% vs 1.0%, P < .0001) were significantly higher after CAS. By multivariate regression, CAS was independently predictive of postoperative stroke (odds ratio [OR], 2.49; 95% confidence interval [CI], 1.91 to 3.25). CAS was also associated with in-hospital postoperative mortality for asymptomatic (OR, 2.37; 95% CI, 1.46 to 3.84) and symptomatic (OR, 2.64; 95% CI, 1.89 to 3.69) patients.
As determined from a large representative national sample including the years 2003 and 2004, the in-hospital stroke rate after CAS for asymptomatic patients was twofold higher than after CEA. For symptomatic patients, the respective in-hospital stroke and mortality rates were fourfold and sevenfold higher. These unexpected results indicate that further randomized controlled trials with homogenous symptomatic and asymptomatic patient groups should be performed.

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    • "Patients were classified as symptomatic if they carried a diagnosis of amaurosis fugax (ICD-9CM 362.34 and 368.12), transient ischemic attack (TIA, ICD-9CM 435.9 and 781.4), or stroke (ICD9-CM 433.11, 433.31, 433.91, 434.01, 434.11, and 434.91). Patients were alternatively considered symptomatic if they carried a discharge diagnosis of carotid artery stenosis with infarction (ICD-9CM 433.11) or carotid artery stenosis without infarction (ICD-9CM 433.10) but with an accompanying diagnosis of TIA [12]. Patients were considered high risk if they met the criteria of Giles et al. [13]. "
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    ABSTRACT: Previous studies have demonstrated an adverse impact of African American race and Hispanic ethnicity on the outcomes of carotid endarterectomy (CEA), although little is known about the influence of race and ethnicity on the outcome of carotid angioplasty and stenting (CAS). The present study was undertaken to examine the influence of race and ethnicity on the outcomes of CEA and CAS in contemporary practice. The nationwide inpatient sample (2005-2008) was queried using International Classification of Diseases-9 codes for CEA and CAS in patients with carotid artery stenosis. The primary outcomes were postoperative death or stroke. Multivariate analysis was performed adjusting for age, gender, race, comorbidities, high-risk status, procedure type, symptomatic status, year, insurance type, and hospital characteristics. Overall, there were 347,450 CEAs and 47,385 CASs performed in the United States over the study period. After CEA, Hispanics had the greatest risk of mortality (P < 0.001), whereas black patients had the greatest risk of stroke (P = 0.02) compared with white patients on univariate analysis. On multivariable analysis, Hispanic ethnicity remained an independent risk factor for mortality after CEA (relative risk 2.40; P < 0.001), whereas the increased risk of stroke in black patients was no longer significant. After CAS, there were no racial or ethnic differences in mortality. On univariate analysis, the risk of stroke was greatest in black patients after CAS (P = 0.03). However, this was not significant on multivariable analysis. Hispanic ethnicity is an independent risk factor for mortality after CEA. While black patients had an increased risk of stroke after CEA and CAS, this was explained by factors other than race. Further studies are warranted to determine if Hispanic ethnicity remains an independent risk factor for mortality after discharge.
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    • "This retrospective study has shown that freedom from stroke both at short term and long term intervals is comparable to results reported in world literature.[1269] Meticulous surgical technique with gentle manipulation of the carotid vessels and use of carotid shunt provided unhurried time for the procedure. "
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    ABSTRACT: Atherosclerotic carotid artery disease poses a grave threat to cerebral circulation, leading to a stroke with its devastating sequelae, if left untreated. Carotid endarterectomy has a proven track record with compelling evidence in stroke prevention. a) To confirm that carotid endarterectomy (CEA) is safe and effective in preventing stroke at both short and long term. b) to demonstrate long term patency of internal carotid artery when arteriotomy repair is performed using autologous saphenous vein patch. During ten years, from September 1997 to February 2008, thirty nine patients who underwent consecutive carotid endarterectomy at our institute, form the basis of this report. Their age ranged from thirty to seventy eight years, with a mean age of 56. There were four women in this cohort. Thirty seven patients were symptomatic with >70% stenosis and two were asymptomatic with >80% stenosis, incidentally detected. Imaging included Duplex scan and MRA for carotid territory and brain, and non-invasive cardiac assessment. Co-morbidities included smoking, hypertension, diabetes, and coronary artery disease. Carotid Endarterectomy was performed under general anaesthesia, using carotid shunt and vein patch arteriotomy repair. All the patients made satisfactory recovery, without major adverse cerebral events in this series. Morbidities included Transient Ischemic Attack (TIA) in two, needing only medications in one, and carotid stenting in the other. Minor morbidities included neck hematoma in two and transient hypoglossal paresis in three patients. Yearly follow-up included duplex scan assessment for all the patients. Two patients died of contralateral stroke, two of myocardial events and two were lost to follow up. Thirty three patients are well and free of the disease during the follow up of three to 120 months. Carotid endarterectomy provided near total freedom from adverse cerebral events and its catastrophic sequelae, leading to excellent outcome, both short as well as long term.
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