Carotid endarterectomy yields better short-term results than carotid artery stenting

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Carotid endarterectomy (CEA) yields better short-term results than carotid artery stenting (CAS) in patients with carotid artery disease, according to a 30-day outcomes report from the Society for Vascular Surgery (SVS) Vascular Registry for Carotid Procedures, published in the January 2009 issue of the Journal of Vascular Surgery.

The SVS Outcomes Committee developed the registry in response to the 2005 Centres for Medicare and Medicaid Services National Coverage Decision on carotid artery stenting. The SVS registry went live on July 2005, as the first societal registry to enroll carotid artery stenting and carotid endarterectomy patients. Data are allocated to visit intervals of 30-day, six-month, one-year, and subsequent annual evaluations.

“As of December 26, 2007, 6,403 procedures with discharge data were entered by 287 providers at 56 centres,” said Flora Siami, New England Research Institutes, Watertown, MA. “In addition there were 1,450 CAS patients and 1,368 CEA patients with 30-day outcomes.”

The primary outcome was combined death, stroke, and myocardial infarction at 30-days post-procedure. The majority of patients were treated because of atherosclerotic disease. Senior author Anton Sidawy, Veterans Affair Medical Centre, Georgetown and George Washington University Schools of Medicine, Washington, DC, said that “In general, there was a greater proportion of CAS patients with pre-procedure lateralising neurological symptoms, as well as higher prevalence of cardiac comorbidities compared with CEA patients.”

Sidawy added that after risk-adjustment for age, history of stroke, diabetes and the American Society of Anesthesiologists’ grade (i.e., factors found to be significant confounders in outcomes using backwards elimination) logistic regression analysis suggested better outcomes following CEA. When CAS and CEA were compared in the treatment of atherosclerotic disease only, the difference in outcomes between the two procedures was more pronounced, with death/stroke/MI 6.42% after CAS vs. 2.62% following CEA, p<.0001. Thus, following best possible risk adjustment of these unmatched groups, symptomatic and asymptomatic CAS patients had significantly higher 30-days post-procedure incidence of death/stroke/myocardial infarction when compared to CEA patients.

Sidawy explained, “Given the trend observed in the Vascular Registry, there is no justification to expand the use of CAS until the results of the randomised CREST trial are published providing level one evidence.”

“This initial report from the Vascular Registry provides proof of concept that a specialty society-based vascular registry can succeed in meeting regulatory and scientific goals,” said Gregorio Sicard, chair, SVS Outcomes Committee, and Washington University in St Louis. “With continued enrollment and follow-up, analysis of SVS Vascular Registry will supplement randomised trials by providing real-world comparisons of CAS and CEA with sufficient numbers to serve as an outcome assessment tool of important patient subsets and across the spectrum of peripheral vascular procedures.”

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