Clinical Referral Patterns for Carotid Artery Stenting Versus Carotid Endarterectomy: Results From the Carotid Artery Revascularization and Endarterectomy Registry

Study Questions:

What are the clinical profiles of patients referred for carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in a large national database?

Methods:

Clinical characteristics of 12,701 patients referred for CAS or CEA in the NCDR® CARE Registry were compared for 44 clinical and demographic variables. To investigate the comparability of CAS and CEA patients, the authors stratified the cohort into quintiles of the propensity score for referral for CAS.

Results:

Among 8,069 patients referred for CAS and 4,632 referred for CEA, the CAS patients had significantly more comorbidities. Whereas the propensity model balanced most covariates, the pooled standardized differences (≥10%) suggested persistent imbalance for ischemic heart disease, recent myocardial infarction, and restenosis of prior CAS/CEA, all of which were more common in the CAS group. After stratification of propensity scores by quintile, CEA patients comprised only 14% of the upper two quintiles.

Conclusions:

The authors concluded that characteristics of patients referred for CAS differ markedly from those referred for CEA.

Perspective:

The study suggests that physician adherence to current guidelines regarding referral for CAS and CEA procedures has resulted in clinically and prognostically important differences in the clinical characteristics of patients treated with these procedures. These extreme clinical differences suggest that conducting comparative effectiveness analyses of alternative treatment strategies for carotid revascularization will require large, clinically enriched data sets and sophisticated analytic methods to ensure that valid comparisons are made to guide future clinical practice, and that these comparisons are properly interpreted so that the limitations of these comparisons are transparently conveyed. Even with the use of sophisticated statistical methods, significant residual bias may remain when comparing groups with extreme differences in baseline characteristics.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Vascular Medicine

Keywords: Registries, Coronary Artery Disease, Myocardial Infarction, Propensity Score, Endarterectomy, Carotid, Carotid Arteries, Carotid Stenosis, Stents


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