Abstract 323: Utilization and Outcomes of Carotid Artery Stenting vs. Carotid Endarterectomy

Introduction: Carotid artery stenting is an alternative to carotid endarterectomy in average surgical-risk symptomatic patients and asymptomatic patients with ≥60% stenosis. We wanted to compare utilization and peri-procedural mortality between these procedures. Methods: The 2000-2013 National Inpatient Sample (NIS) was analyzed for admissions when procedures for carotid artery stenting (CAS) or carotid endarterectomy (CEA) were performed. Admissions when both procedures were performed were excluded. Trend of procedures and death during index admission was compared depending on prior cerebrovascular symptoms. Results: During the study period, 1991941 patients underwent CEA of which 9.12% were symptomatic and 343,741 patients underwent CAS of which 10.8% were symptomatic. Mean age for CAS vs CEA group was lower among both symptomatic (68.6 vs 69.6 yrs, p<0.001) and asymptomatic patients (70.7 vs 71.2 yrs, p<0.001). More males than females underwent CAS (57% vs 43%) and CEA (58% vs 42%). Both CAS and CEA during same admission was carried out in 20,875 (0.89%) patients. There was a rising trend of both CEA and CAS procedures in symptomatic and asymptomatic patients (ptrend < 0.001)(Figure A1 & B1). Trend of mortality has not changed significantly in all groups except for CEA in asymptomatic patients wherein mortality rate has decreased (ptrend <0.001)(Figure A2 & B2). On multivariable logistic regression analysis, associated conditions significant for mortality in symptomatic patients were atrial fibrillation (OR 2.05, p<0.001), myocardial infarction (OR 1.61, p=0.001) heart failure (OR 1.39, p=0.021) and malnutrition (OR 3.58, p<0.001). Adjusted likelihood of mortality after CAS vs CEA was higher in symptomatic (OR 3.78, p<0.001, C statistic 0.74) and asymptomatic patients (OR 2.00, p<0.001, C statistic 0.80). Conclusion: Utilization of CAS and CEA has increased over time. Mortality after CAS vs. CEA during index admission, remains high.

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Selection of Treatment for Patients with Carotid Artery Disease: Medication, Carotid Endarterectomy, or Carotid Artery Stenting

Vascular ◽

10.1258/rsmvasc.13.2.92 ◽

2005 ◽

Vol 13 (2) ◽

pp. 92-97 ◽

Cited By ~ 3

Author(s):

Marc Bosiers ◽

Patrick Peeters ◽

Koen Deloose ◽

Jürgen Verbist ◽

L. Richard Sprouse

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Medical Therapy ◽

Carotid Artery Stenting ◽

Carotid Artery Disease ◽

Limiting Factors ◽

Treatment Modalities ◽

Asymptomatic Patients ◽

Artery Disease ◽

Selection Of

Patients presenting with atherosclerosis of the extracranial carotid arteries may be offered carotid endarterectomy (CEA), carotid artery stenting (CAS), or medical therapy to reduce their risk of stroke. In many cases, the choice between treatment modalities remains controversial. An algorithm based on patients' neurologic symptoms, comorbidities, limiting factors for CAS and CEA, and personal preferences was developed to determine the optimal treatment in each case. This algorithm was then employed to determine therapy in 308 consecutive patients presenting to a single institution during one calendar year. Ninety-five (30.8%) patients presented with an asymptomatic carotid stenosis of more than 80% and 213 (69.2%) with a symptomatic stenosis of more than 50%. According to our algorithm, 59 (62.1%) of the 95 asymptomatic patients received CAS, 20 (21.1%) received CEA, and 16 (16.8%) received medical therapy. All symptomatic patients underwent intervention; 153 (71.8%) were treated with CAS and 60 (28.2%) with CEA. Combined 30-day stroke and death rates after CAS were 1.7% in asymptomatic patients and 2.6% in symptomatic patients. After CEA, these rates were 0% and 3.3%, respectively. Careful selection of treatment modality according to predetermined criteria can result in improved outcomes.

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Early results of carotid endarterectomy versus carotid stenting: Outcomes from a Mediterranean country

Vascular ◽

10.1177/1708538119841451 ◽

2019 ◽

Vol 27 (5) ◽

pp. 468-474

Author(s):

Ricardo Castro-Ferreira ◽

Alberto Freitas ◽

Sérgio M Sampaio ◽

Paulo G Dias ◽

Armando Mansilha ◽

...

Keyword(s):

Carotid Artery ◽

Hospital Mortality ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Carotid Artery Stenting ◽

Public Hospitals ◽

Hospital Length Of Stay ◽

Mediterranean Country ◽

Main Diagnosis ◽

Asymptomatic Patients

Introduction and objectives Which is the best carotid stenosis treatment remains a controversial issue. To present day, no study has compared the results of carotid artery stenting versus carotid endarterectomy in Portugal. We aim to provide real life numbers regarding the outcomes of both procedures in Portuguese public hospitals. Methods Every patient registered between 2005 and 2015 with the main diagnosis of carotid stenosis and submitted to carotid endarterectomy or carotid artery stenting was included. The information was obtained through the Central National Healthcare Administrative database, a mandatory registry for hospital refunding. Primary outcomes were hospital mortality and stroke. Patient demographics, comorbidities and hospital length of stay were also evaluated. Results The study included 6094 patients: 1399 were symptomatic (mention of prior stroke) and 4695 asymptomatic. Carotid artery stenting was performed on 22% of the symptomatic and 18% of the asymptomatic patients. In the symptomatic patients, the in-hospital mortality was significantly higher in those submitted to stenting (3.6% vs. 1.6% in carotid endarterectomy, p = 0.025). No significant differences in outcomes were observed in the asymptomatic group (mortality 0.9% vs. 0.8%, p = 0.852; stroke rate of 2.6% vs. 2.3%, p = 0.652 – carotid artery stenting vs. carotid endarterectomy). In both groups, there was an important increase in the proportion of stenting between 2005 and 2012, followed by a gradual decline until 2015. Conclusion Despite its increasing frequency, a higher early mortality was documented for CAS in symptomatic patients. No worse outcome was observed in asymptomatic patients.

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Stent-Protected Angioplasty in Asymptomatic Carotid Artery Stenosis vs. Endarterectomy: SPACE2 – a Three-Arm Randomised-Controlled Clinical Trial

International Journal of Stroke ◽

10.1111/j.1747-4949.2009.00290.x ◽

2009 ◽

Vol 4 (4) ◽

pp. 294-299 ◽

Cited By ~ 66

Author(s):

T. Reiff ◽

R. Stingele ◽

H. H. Eckstein ◽

G. Fraedrich ◽

O. Jansen ◽

...

Keyword(s):

Primary Prevention ◽

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Carotid Artery Disease ◽

Controlled Clinical Trial ◽

Vascular Events ◽

Asymptomatic Carotid ◽

Symptomatic Carotid ◽

Asymptomatic Patients

Moderate to severe (≥70%) asymptomatic stenosis of the extracranial carotid artery leads to an increased rate of stroke of approximately 11% in 5 years. Patients with asymptomatic carotid stenosis, however, are also at a higher risk of nonstroke vascular events. The estimated annual risks of such events in patients with asymptomatic stenosis are 7% for a coronary ischaemic event and 4–7% for overall mortality. The superiority of carotid endarterectomy compared with medical treatment in symptomatic carotid disease is established, provided that the surgical procedure can be performed with a perioperative morbidity and mortality of <6%. The advantage of carotid endarterectomy for asymptomatic patients is less established. An alternative treatment, carotid artery stenting, has been developed. This treatment is used frequently in both symptomatic and asymptomatic patients. In the last decade, major advantages in medical primary prevention of cerebrovascular and cardiovascular disease have been accomplished. The control groups in the large trials for asymptomatic carotid artery disease (ACAS and ACST) originate from more than a decade ago and, for the most part, have not received a medical primary prevention strategy that would now be considered the standard according to current national and international guidelines. For this reason, a three-arm trial (SPACE2; http://www.space-2.de ) with a hierarchical design and a recruitment target of 3640 patients is chosen. Firstly, a superior trial of intervention (carotid artery stenting or carotid endarterectomy) vs. state-of-the-art conservative treatment is designed. In case of superiority of the interventions, a noninferiority end-point will be tested between carotid artery stenting and carotid endarterectomy. This trial is registered at Current Controlled Trials ISRCTN 78592017.

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Recent Update on Carotid Endarterectomy versus Carotid Artery Stenting

Cerebrovascular Diseases ◽

10.1159/000453282 ◽

2016 ◽

Vol 43 (1-2) ◽

pp. 68-75 ◽

Cited By ~ 20

Author(s):

Raywat Noiphithak ◽

Anusak Liengudom

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Current Data ◽

Current Evidence ◽

Stroke Treatment ◽

Carotid Revascularization ◽

Asymptomatic Patients ◽

Best Medical Treatment ◽

Meta Analyses

Carotid artery stenosis (CS) is a major cause of ischemic stroke. Treatment of CS consists of best medical treatment and carotid revascularization (CR), including carotid endarterectomy (CEA) and carotid artery stenting (CAS). Both CR techniques have their own procedural risks. Therefore, selection of the appropriate treatment for patients with CS is relatively complicated. Many studies and guidelines have reported the efficacy of each treatment for both symptomatic and asymptomatic patients. However, the results are still controversial, especially concerning the efficacy and safety of CEA and CAS. In this paper, we review and discuss the current evidence and compare results from studies of CEA and CAS, including major randomized trials, meta-analyses and ongoing trials. Moreover, based on the current data, we propose a new comprehensive decision-making for the management of CS.

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Complication-Specific In-Hospital Costs After Carotid Endarterectomy vs Carotid Artery Stenting

Journal of Endovascular Therapy ◽

10.1177/1526602818781580 ◽

2018 ◽

Vol 25 (4) ◽

pp. 514-521 ◽

Cited By ~ 1

Author(s):

Hanaa Dakour-Aridi ◽

Besma Nejim ◽

Satinderjit Locham ◽

Husain Alshaikh ◽

Tammam Obeid ◽

...

Keyword(s):

Carotid Artery ◽

Incremental Cost ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Logistic Models ◽

Complication Rates ◽

Healthcare Database ◽

Asymptomatic Patients ◽

Significant Difference ◽

Hospitalization Costs

Purpose: To quantify and compare the incremental cost associated with in-hospital stroke, death, and myocardial infarction (MI) after carotid endarterectomy (CEA) vs carotid artery stenting (CAS). Methods: A retrospective analysis was performed of 100,185 patients (mean age 70.7±9.5 years; 58.3% men) who underwent CEA (n=86,035) or CAS (n=14,150) between 2009 and 2015 and were entered into the Premier Healthcare Database. Multivariate logistic models and generalized linear models were used to analyze binary outcomes and hospitalization costs, respectively. Outcomes are presented as the adjusted odds ratio (aOR) and 95% confidence interval (CI). Results: CAS was associated with 1.6 times higher adjusted odds of stroke [aOR 1.55 (95% CI 1.36 to 1.77), p<0.001] and with 2.6 times higher odds of death [aOR 2.60 (95% CI 2.14 to 3.17), p<0.001] compared with CEA. There was no significant difference in MI risk between the 2 procedures. The adjusted incremental cost of death and MI were similar between the 2 procedures. However, the adjusted incremental cost of stroke was significantly higher in CEA compared with CAS by an estimated $2000. When stratified with respect to symptomatic status, the increased adjusted incremental cost of stroke in CEA was mainly seen in asymptomatic patients ($5284 vs $2932, p<0.01). Conclusion: The incremental cost of in-hospital stroke is relatively higher in CEA compared to CAS. However, CEA remains a more cost-effective carotid intervention due to lower complication rates and baseline costs compared with CAS. Long-term cost-effectiveness studies are needed before definite conclusions are made.

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Increased Hospital Use of Carotid Artery Stenting (CAS) Over Carotid Endarterectomy (CEA) is Associated With Inferior Outcomes in Asymptomatic Patients

Journal of Vascular Surgery ◽

10.1016/j.jvs.2011.11.077 ◽

2012 ◽

Vol 55 (2) ◽

pp. 622 ◽

Cited By ~ 1

Author(s):

Theodore H. Yuo ◽

Howard Degenholtz ◽

Rabih A. Chaer ◽

Kevin L. Kraemer ◽

Michel S. Makaroun

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Asymptomatic Patients ◽

Hospital Use

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Effect of hospital-level variation in the use of carotid artery stenting versus carotid endarterectomy on perioperative stroke and death in asymptomatic patients

Journal of Vascular Surgery ◽

10.1016/j.jvs.2012.09.036 ◽

2013 ◽

Vol 57 (3) ◽

pp. 627-634 ◽

Cited By ~ 8

Author(s):

Theodore H. Yuo ◽

Howard S. Degenholtz ◽

Rabih A. Chaer ◽

Kevin L. Kraemer ◽

Michel S. Makaroun

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Level Variation ◽

Hospital Level ◽

Perioperative Stroke ◽

Asymptomatic Patients

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Prediction models for clinical outcome after a carotid revascularisation procedure: A systematic review

European Stroke Journal ◽

10.1177/2396987317739122 ◽

2017 ◽

Vol 3 (1) ◽

pp. 57-65 ◽

Cited By ~ 3

Author(s):

Eline J Volkers ◽

Ale Algra ◽

L Jaap Kappelle ◽

Jacoba P Greving

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Carotid Artery Stenting ◽

Prediction Models ◽

Term Outcome ◽

Discriminative Performance ◽

Long Term Outcome ◽

C Statistic

Introduction Prediction models for clinical outcome after carotid artery stenting or carotid endarterectomy could aid physicians in estimating peri- and postprocedural risks in individual patients. We aimed to identify existing prediction models for short- and long-term outcome after carotid artery stenting or carotid endarterectomy in patients with symptomatic or asymptomatic carotid stenosis, and to summarise their most important predictors and predictive performance. Patients and methods We performed a systematic literature search for studies that developed a prediction model or risk score published until 22 December 2016. Eligible prediction models had to predict the risk of vascular events with at least one patient characteristic. Results We identified 37 studies that developed 46 prediction models. Thirty-four (74%) models were developed in carotid endarterectomy patients; 27 of these (59%) predicted short-term (in-hospital or within 30 days) risk. Most commonly predicted outcome was stroke or death (n = 12; 26%). Age (n = 31; 67%), diabetes mellitus (n = 21; 46%), heart failure (n = 16; 35%), and contralateral carotid stenosis ≥50% or occlusion (n = 16; 35%) were most commonly used as predictors. For 25 models (54%), it was unclear how missing data were handled; a complete case analysis was performed in 15 (33%) of the remaining 21 models. Twenty-eight (61%) models reported the full regression formula or risk score with risk classification. Twenty-one (46%) models were validated internally and 12 (26%) externally. Discriminative performance (c-statistic) ranged from 0.66 to 0.94 for models after carotid artery stenting and from 0.58 to 0.74 for models after carotid endarterectomy. The c-statistic ranged from 0.55 to 0.72 for the external validations. Discussion Age, diabetes mellitus, heart failure, and contralateral carotid stenosis ≥50% or occlusion were most often used as predictors in all models. Discriminative performance (c-statistic) was higher for prediction models after carotid artery stenting than after carotid endarterectomy. Conclusion The clinical usefulness of most prediction models for short- or long-term outcome after carotid artery stenting or carotid endarterectomy remains unclear because of incomplete reporting, methodological limitations, and lack of external validation.

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