Earlier this year Gary Roubin, chairman, Department of Interventional Cardiology at Lenox Hill Hospital, NY, suggested that the primary reason that carotid stenting is limited by the Centers for Medicare and Medicaid Services is because of the ‘sub-optimal’ outcomes even from so called ‘experienced’ operators. This was due to poor patient and stent selection, and a poor technique. Speaking at the International Symposium on Endovascular Therapy (ISET) 2007, in Miami, FL, he argued that the experience of an operator, not their speciality, is critical in the outcome of patients undergoing carotid artery stenting.
He cited data from the CREST lead-in registry, a NIH study. All participating physicians (radiologists, radiologists and surgeons) had previous carotid stent experience. An assessment of the patient group showed that older patients (>70 yrs.) had a greater incidence of adverse (contraindicated) anatomy – arch, lesion tortuosity and calcification. According to Roubin, such characteristics challenged patient selection as well as the technical skills of the operator.
An initial trend had suggested improved results of CAS by neurointerventionalists and cardiologists as compared with interventional radiologists and neuro-vascular surgeons was identified. According to Roubin, the crucial difference in the results between the specialty was the ability of interventional cardiologists to recognize those patients who were at low risk of stenting, because on average interventional cardiologists were early adopters of carotid stenting (operator experience).
However, Robert Hobson who is the Principal Investigator of CREST told the audience at the recent Charing Cross International Symposium 2007, in London, UK, that with initial and further analyses of the data, this trend proved to be non significant (p>0.05). CREST did not include evaluation of speciality performance as a secondary goal in its protocol. No provisions were made to balance the number or severity of associated co-morbidities of cases performed by individuals from these groups of rigorously credentialed interventionalists. This point is picked up by Hobson in the CREST editorial clarification on page 10 in this issue.