Risk-adjusted 30-day outcomes of carotid stenting
and endarterectomy: Results from the SVS
Vascular Registry

Sarasota Vascular Specialists Article Summary and Comment:

Carotid endarterectomy (CEA) yields better short-term results than carotid artery stenting (CAS) in patients with carotid artery disease, according to a 30-day outcomes report from the Society for Vascular Surgery (SVS) Vascular Registry for Carotid Procedures, published in the January 2009 issue of the Journal of Vascular Surgery.

The SVS Outcomes Committee developed the registry in response to the 2005 Centers for Medicare and Medicaid Services National Coverage Decision on carotid artery stenting which insisted that in order to be compensated for CAS, institutions had to submit their data to a national registry. The SVS registry went live on July 2005, as the first societal registry to enroll carotid artery stenting and carotid endarterectomy patients. Data are allocated to visit intervals of 30-day, six-month, one-year, and subsequent annual evaluations. As of December 26, 2007, 6,403 procedures with discharge data were entered by 287 providers at 56 centers.

The primary outcome was combined death, stroke, and myocardial infarction at 30-days post-procedure. The majority of patients were treated because of atherosclerotic disease. In general, there was a greater proportion of CAS patients with pre-procedure lateralizing neurological symptoms, as well as higher prevalence of cardiac comorbidities compared with CEA patients. However, after risk-adjustment for age, history of stroke, diabetes and the American Society of Anesthesiologists’ grade (i.e., factors found to be significant confounders in outcomes using backwards elimination) logistic regression analysis suggested better outcomes following CEA. When CAS and CEA were compared in the treatment of atherosclerotic disease only, the difference in outcomes between the two procedures was more pronounced, with death/stroke/MI 6.42% after CAS vs. 2.62% following CEA, p<.0001. Thus, following best possible risk adjustment of these unmatched groups, symptomatic and asymptomatic CAS patients had significantly higher 30-days post-procedure incidence of death/stroke/myocardial infarction when compared to CEA patients.

Given the trend observed in the Vascular Registry, we believe that there is no justification to expand the use of CAS until the results of the randomized CREST trial are published providing level one evidence. Accordingly, we perform CAS only when there are strict contraindications to surgery which we believe currently occur mainly due to anatomical conditions such as radiated necks, high lesions etc. It is extremely unusual that medical conditions will preclude CEA. Further we would like to reiterate that all current studies on CAS include a large proportion of recurrent lesions following CEA. This favors CAS since these lesions are often benign and when symptomatic pose less of a risk for CAS since they are usually solid lesions without intra-plaque hemorrhage or ulceration and hence pose less of a risk for atheroembolization during CAS. We have recently presented our results of 2027 CEAs and 36 CAS. The stroke rate for CEA was 0.87%

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