Carotid artery stenting and carotid endarterectomy lead to similar outcomes in Medicare patients

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After adjusting for patient- and provider-level factors, Medicare patients had similar rates of death, stroke/transient ischemic attack, periporocedural MI and a composite of those outcomes if they underwent carotid artery stenting or carotid endarterectomy, according to a retrospective cohort study.

The researchers also adjusted for patient-level factors only and found carotid artery stenting was associated with a higher mortality risk, which suggested provider characteristics and proficiency could impact the effectiveness of coronary artery stenting.

Lead researcher Jessica J. Jalbert, PhD, of Brigham and Women’s Hospital and Harvard Medical School in Boston, and colleagues published their results online in  Circulation: Cardiovascular Quality and Outcomes on April 27.

For this study, the researchers analyzed 5,254 patients from the Society for Vascular Surgery Vascular Registry (SVS-VR) and 4,055 patients from the National Cardiovascular Data Registry's Carotid Artery Revascularization and Endarterectomy Registry (CARE). They linked outcomes from the registries with Medicare data.

All of the patients were Medicare fee-for-service beneficiaries who were at least 66 years old and enrolled in Medicare for at least one year before undergoing their first carotid artery stenting or carotid endarterectomy.

The researchers mentioned that patients undergoing carotid artery stenting were sicker, had more comorbidities and were predominantly at high surgical risk compared with patients undergoing carotid endarterectomy, which they said was in line with previous research.

They also noted that the distribution of age, sex, race, trial enrollment, type of hospital admission and overall comorbidity burden was similar for SVS-VR and CARE patients. However, CARE patients were less often symptomatic.

Cardiologists performed 56 percent of carotid artery stenting procedures, while vascular surgeons performed 37 percent of carotid endarterectomy procedures.

The unadjusted risks of death and stroke were higher for patients undergoing carotid artery stenting, but those differences were attenuated when adjusting for patient- and provider-level factors. Examples of provider-level factors were past-year physician and hospital procedural volume, teaching affiliation, stroke center status and hospital size.

The researchers also found a non-significant trend that suggested carotid endarterectomy might be associated with a lower risk of adverse outcomes in patients who were 80 years old or older and had symptomatic carotid artery stenosis.

They said the main limitation of the study was that it lacked the power and ability to stratify estimates across subgroups of patients such as those with restenosis and contralateral occlusion. They also did not consider stroke territory. In addition, they relied on claims-based data for stroke/transient ischemic attack and MI, which only included events that resulted in hospitalizations. Further, they did not include carotid revascularizations with medical management.