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National Trends in Utilization and Postprocedure Outcomes for Carotid Artery Revascularization 2005 to 2007
Study Questions:
What are the trends in utilization, mortality, and stroke after carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA) from 2005 to 2007?
Methods:
The Nationwide Inpatient Sample (NIS) was queried for patient discharges with International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes for CAS and CEA. The primary outcomes were in-hospital mortality, stroke, hospital charges, and discharge disposition. Subgroup analyses were performed to evaluate these outcomes by neurologic presentation using χ2 and multivariable logistic regression.
Results:
Of the 404,256 discharges for carotid revascularization, CAS utilization was 66% higher in 2006 than in 2005 (9.3% vs. 14%, p = 0.0004). Crude mortality, stroke, and median charges remained higher for CAS than for CEA; discharge to home was more common after CEA. Results improved from 2005 to 2007. By logistic regression of the total cohort from 2005 to 2006, CAS was independently predictive of mortality (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.08-2.00; p < 0.0001). Independent predictors of stroke included CAS (OR, 1.43; 95% CI, 1.18-1.73; p < 0.0001) and symptomatic disease (OR, 2.4; 95% CI, 2.06-2.93; p < 0.0001). Among subgroups based on neurological presentation, logistic regression showed that CAS significantly increased the odds of stroke in asymptomatic patients (OR, 1.6; 95% CI, 1.2-2.0; p = 0.0003). Among symptomatic patients, CAS increased the odds of in-hospital death (OR, 3.0; 95% CI, 1.7-5.1; p < 0.0001) and trended toward significance for stroke (OR, 1.7; 95% CI, 1.0-2.8; p = 0.0569).
Conclusions:
The authors concluded that utilization of CAS has increased from the years 2005 to 2007.
Perspective:
In this retrospective observational study of the most recently available national data (2007), the authors found that during the first 3 years after Food and Drug Administration (FDA) approval of CAS, patients undergoing CAS had significantly higher overall rates of postoperative stroke and in-hospital mortality than those undergoing CEA. By separate analysis, for patients with asymptomatic carotid artery stenosis, CAS was associated with a higher postoperative stroke rate than CEA. Given the limitations of studies based on administrative data sets, long-term follow-up of randomized unbiased clinical trials is needed to define the true risk/benefit of both CEA and CAS in the contemporary era, and to answer questions about the ‘cost-effectiveness’ of carotid revascularization.
Keywords: Follow-Up Studies, Hospital Mortality, International Classification of Diseases, Endarterectomy, Carotid, Carotid Arteries, Angioplasty, Carotid Stenosis, Patient Discharge, United States, Stents
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