JVS Feature: Carotid stenting more costly, riskier than endarterectomy
CT images in 89-year-old woman with admission NIHSS score of 18 obtained 133 minutes after stroke.
Utilizing carotid artery stenting (CAS) as the gold standard to repair stenosis remains unlikely despite improvement in outcomes due to higher costs and an increased risk of mortality and stroke compared to carotid endarterectomy (CEA), which is particularly true for patients who present with neurological symptoms, based on a study published online Nov. 19 in the Journal of Vascular Surgery.

“Since the endovascular technique was first described in the early 1990s, proponents of CAS have cited its less invasive nature as an alternative to carotid endartrectomy particularly in 'high risk' patients without a clear definition of such patients,” the authors wrote.

Previous studies have compared post-procedural results of CAS and CEA in both symptomatic and asymptomatic patients; the results have been conflicting, particularly surrounding the role of CAS for the treatment of carotid artery stenosis.

Mohammad H. Eslami, MD, from the University of Massachusetts Medical School in Worcester, Mass., and colleagues used Nationwide Inpatient Sample data to evaluate national utilization, mortality and stroke trends of either carotid angioplasty and CAS and CEA between 2005 and 2007.

Eslami and colleagues used in-hospital mortality, stroke, hospital charges and discharge disposition as the study’s primary outcomes.

Out of 404,256 discharges for carotid revascularization, CAS utilization was higher in 2006 compared with 2005, 14 percent versus 9.3 percent.

The researchers found that patients were more likely to be discharged to the home after CEA procedures. And while rates of  crude mortality were higher for CAS patients, mortality rates for CAS decreased between 2005 and 2007, from 4.6 percent to 3.6 percent.

In addition, CAS was shown to be an independent predictor of mortality, while CAS and symptomatic diseases were independent predictors of stroke.

“The results show that CEA is better among the patients who have neurological symptoms when they presented at the hospital ... and that was true across all age groups,” Eslami told Cardiovascular Business News.

Asymptomatic disease was common in 91.8 percent of the patient cohort and 57.8 percent of the revascularizations were performed on male patients compared with only 38.6 percent performed in female patients who underwent a CAS procedure.

Based on neurological presentation, CAS increased the odds of stroke in asymptomatic patients and CAS increased the odds of in-hospital death and stroke among symptomatic patients. And while the outcomes for CAS are slightly worse than CEA, they are improving, Eslami said.

Researchers also found that CAS patients were twice as likely to die in the hospital compared with those undergoing CEA, 0.84 percent versus 0.45 percent. CAS was associated with higher rates of post-procedure stroke, 1.4 percent versus 0.96 percent.

While the rates of post-operative stroke were higher among asymptomatic CAS patients (1.3 percent vs. 0.86 percent), the researchers also found that stroke rates were higher among symptomatic CAS patients compared with CEA, 3.1 percent versus 2.1 percent; however, the researchers called the differences not statistically significant.

“These results are an extension of previous papers on these topics,” Eslami noted. “The results that we found were relatively similar to the very large, multicenter prospective trial CREST.”

Additionally, Eslami said, “The other results that we found were that carotid endarterectomy was significantly less expensive than carotid stenting." Resource utilization was significantly higher for CAS, and CAS patients were more likely to be discharged to another hospital rather than home, 7.1 percent versus 5.6 percent.

Median hospital cost for CAS was higher for symptomatic patients, more than $19,000 versus $12,000-plus for the overall cohort of patients. But "it is difficult to pinpoint the reason for this increase in utilization of CAS," the researchers wrote.

However, the researchers did note that this discrepency could be due to the increased post-operative stroke rate, which often leads to the utilization of ancillary services.

Eslami also offered that “CEA has been around for many years and has gone through many trials that have found it to be superior to other medical treatments, especially in symptomatic patients.

“CAS is another procedure that can be used to treat this disease, but in symptomatic patients and given the costs, it doesn’t seem to be approaching the same status as endarterectomy.

“While the results don’t have a direct impact on the clinical practice, they will provide a cautionary note for using stenting as opposed to endarterectomy,” Eslami concluded.