National trends in carotid artery revascularization surgery

Clinical article

Restricted access

Object

Several randomized trials have emerged with conflicting data on the overall safety of carotid artery stenting (CAS) in comparison with carotid endarterectomy (CEA). The authors hypothesize that changes in national trends correspond to publication of randomized trials, including an increase in utilization of CAS after publication of trials favorable to CAS (for example, Carotid and Vertebral Artery Transluminal Angioplasty Study [CAVATAS] and Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy [SAPPHIRE]) and decrease in utilization of CAS after publication of trials favorable to CEA (for example, Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis [EVA3-S] and Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy [SPACE]).

Methods

The Nationwide Inpatient Sample was obtained for the years 1998–2008. Individual cases were isolated for principal diagnosis of unilateral or bilateral carotid artery stenosis or occlusion undergoing CEA or CAS. The percentage of CAS for all carotid revascularization procedures was calculated for each year. Perioperative inpatient morbidity, including stroke or death, were calculated and compared.

Results

The percentage of patients undergoing CAS increased yearly from the start of the observed period to the end, with the exception of a decrease in 2007. The peak utilization of CAS for carotid artery revascularization procedures was 15% of all cases in 2006. The stroke or death rate was consistent at 5% among all patients undergoing CEA for all years, while the incidence of stroke or death decreased among patients undergoing CAS from 9% in 1998 to 5% in 2008.

Conclusions

The practice of CAS in the US is expanding, from less than 3% of all carotid artery revascularization procedures to 13% in 2008. The utilization of CAS was seen to correlate with publication of randomized trials. Utilization nearly doubled in 2005 after publication of the CAS-favorable SAPPHIRE in 2004, and decreased by 22% after publication of the CEA-favorable EVA-3S and SPACE in 2007. With the publication of Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), the authors predict a resultant increase in the rate of CAS for carotid artery disease in the upcoming years.

Abbreviations used in this paper:ACAS = Asymptomatic Carotid Atherosclerosis Study; CAS = carotid artery stenting; CAVATAS = Carotid and Vertebral Artery Transluminal Angioplasty Study; CEA = carotid endarterectomy; CREST = Carotid Revascularization Endarterectomy Versus Stenting Trial; EVA-3S = Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis; ICSS = International Carotid Stenting Trial; NASCET = North American Symptomatic Carotid Endarterectomy Trial; NIS = Nationwide Inpatient Sample; SAPPHIRE = Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy; SPACE = Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy.

Article Information

Address correspondence to: Travis M. Dumont, M.D., Division of Neurosurgery, University of Vermont, 111 Colchester Avenue, Fletcher 507, Burlington, Vermont 05401. email: travisdumont@gmail.com.

Please include this information when citing this paper: published online April 6, 2012; DOI: 10.3171/2012.3.JNS111320.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Graph showing that CAS utilization increased during the study period, from 3% to 13% of all carotid revascularization procedures. A 45% increase in utilization of CAS is seen in 2005 after publication of SAPPHIRE in 2004. A 20% decrease in the number of CAS performed in 2007 coincides with the publication of EVA-3S and SPACE in 2006. Both of these studies were unfavorable to CAS procedures compared with CEA.

  • View in gallery

    The stroke or death rate after CEA was consistent at about 5% annually, while the incidence of inpatient stroke or death following CAS decreased from 9% to 5% over the study period.

References

1

Bettmann MAKatzen BTWhisnant JBrant-Zawadzki MBroderick JPFurlan AJ: Carotid stenting and angioplasty: a statement for healthcare professionals from the Councils on Cardiovascular Radiology, Stroke, Cardio-Thoracic and Vascular Surgery, Epidemiology and Prevention, and Clinical Cardiology, American Heart Association. Stroke 29:3363381998

2

CAVATAS Investigators: Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 357:172917372001

3

Ederle JDobson JFeatherstone RLBonati LHvan der Aorp HBde Borst GJ: Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 357:9859972010

4

Elixhauser ASteiner CHarris DRCoffey RM: Comorbidity measures for use with administrative data. Med Care 36:8271998

5

Faries PLChaer RAPatel SLin SCDeRubertis BKent KC: Current management of extracranial carotid artery disease. Vasc Endovascular Surg 40:1651752006

6

Fields WSMaslenikov VMeyer JSHass WKRemington RDMacdonald M: Joint study of extracranial arterial occlusion. V. Progress report of prognosis following surgery or nonsurgical treatment for transient cerebral ischemic attacks and cervical carotid artery lesions. JAMA 211:199320031970

7

Grube EGerckens UYeung ACRowold SKirchhof NSedgewick J: Prevention of distal embolization during coronary angioplasty in saphenous vein grafts and native vessels using porous filter protection. Circulation 104:243624412001

8

Harjai KJMehta RH: Trials and tribulations of carotid artery stenting: the interventionalists' perspective on SAPPHIRE, EVA-3S, and SPACE Trials. J Interv Cardiol 20:3893942007

9

Hobson RW II: Rationale and status of randomized controlled clinical trials in carotid artery stenting. Semin Vasc Surg 16:3113162003

10

Kastrup AGröschel KKrapf HBrehm BRDichgans JSchulz JB: Early outcome of carotid angioplasty and stenting with and without cerebral protection devices: a systematic review of the literature. Stroke 34:8138192003

11

Lang POSchwarze MLAlexander GC: New technologies meeting old professional boundaries: the emergence of carotid artery stenting. J Am Coll Surg 200:8548602005

12

Mantese VATimaran CHChiu DBegg RJBrott TG: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): stenting versus carotid endarterectomy for carotid disease. Stroke 41:10 SupplS31S342010

13

Mas JLChatellier GBeyssen BBranchereau AMoulin TBecquemin JP: Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 355:166016712006

14

North American Symptomatic Carotid Endarterectomy Trial Collaborators: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:4454531991

15

Ringleb PAAllenberg JBrückmann HEckstein HHFraedrich GHartmann M: 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 368:123912472006

16

Shaw DAVenables GSCartlidge NEBates DDickinson PH: Carotid endarterectomy in patients with transient cerebral ischaemia. J Neurol Sci 64:45531984

17

Veith FJAmor MOhki TBeebe HGBell PRBolia A: Current status of carotid bifurcation angioplasty and stenting based on a consensus of opinion leaders. J Vasc Surg 33:2 SupplS111S1162001

18

Yadav JSWholey MHKuntz REFayad PKatzen BTMishkel GJ: Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 351:149315012004

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 58 58 20
Full Text Views 147 147 18
PDF Downloads 96 96 7
EPUB Downloads 0 0 0

PubMed

Google Scholar