Outcomes After Carotid Artery Stenting and Endarterectomy in the Medicare Population

Abstract

Background and Purpose-Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for stroke prevention. The value of this therapy relative to CEA remains uncertain. Methods-In 10 958 Medicare patients aged 66 years or older between 2004 and 2006, we analyzed in-hospital, 1-year stroke, myocardial infarction, and death rate outcomes and the effects of potential confounding variables. Results-CAS patients (87% were asymptomatic) had a higher baseline risk profile, including having a higher percentage of coronary and peripheral arterial disease, heart failure, and renal failure. In-hospital stroke rate (1.9% CAS versus 1.4% CEA; Pϭ0.14) and mortality (CAS 0.9% versus 0.6% CEA; Pϭ0.20) were similar. By 1 year, CAS patients had similar stroke rates (5.3% CAS versus 4.1% CEA; Pϭ0.12) but higher all-cause mortality rates (9.9% CAS versus 6.1% CEA; PϽ0.001). Using Cox multivariable models, there was a similar stroke risk (hazard ratio, 1.28; 95% CI, 0.90 -1.79) but CAS patients had a significantly higher mortality (HR, 1.32; 95% CI, 1.02-1.71). Sensitivity analyses suggested that unmeasured confounders could be responsible for the mortality difference. In multivariable analysis, stroke risk was highest in the patients symptomatic at the time of revascularization. Conclusions-CAS patients had a similar stroke risk but an increased mortality rate at 1 year compared with CEA patients, possibly related to the higher baseline risk profile in the CAS patient group.

Early Outcomes After Carotid Artery Stenting Compared With Endarterectomy for Asymptomatic Carotid Stenosis

“…Despite the fact that >90% of carotid revascularization procedures are performed for patients with asymptomatic carotid stenosis, 22,23 and that a substantial proportion of these procedures are currently done using CAS, there is no highlevel evidence that supports the use of CAS for these patients. CAS indicates carotid artery stenting; CEA, carotid endarterectomy; CI, confidence interval; MI, myocardial infarction; and OR, odds ratio (of outcome with carotid artery stenting compared with carotid endartectomy.…”

Cost-Effectiveness of Carotid Plaque MR Imaging as a Stroke Risk Stratification Tool in Asymptomatic Carotid Artery Stenosis

“…The results of these older studies are now largely outdated, as medical of future stroke by 46% (16). We chose ACST-1 to provide a stroke relative risk after CEA rather than including and pooling the results of the three existing major trials of medical therapy versus CEA in asymptomatic CAS, which, in underwent CEA) were nonfatal perioperative strokes (16,17,19). According to the largest and most recent applicable randomized controlled trial, ACST-1, which was published in 2010, CEAs without complications reduced the risk analysis was conducted from a healthcare system perspective over a lifetime horizon, with all costs in 2013 dollars, and future healthcare costs and QALYs were discounted at 3% annually (43).…”

Cost-Effectiveness of Carotid Plaque MR Imaging as a Stroke Risk Stratification Tool in Asymptomatic Carotid Artery Stenosis

“…Finally, our sensitivity analysis results were affected by the uncertainty around the cost and complication rate of CEA. Our complication rate estimate was based on Medicare data from 2004 through 2006 in nearly 10 000 patients undergoing CEA (17). Thus, although it likely provides a reasonable national complication rate, the use of aggregate administrative database data prevents many specific patient and provider…”