An evaluation of trends in the utilisation of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) has found there to be “no major change” to tip the balance following the 2023 US Centers for Medicare and Medicaid Services (CMS) expansion of CAS coverage to include standard-risk patients with symptomatic ≥50% and asymptomatic ≥70% carotid artery stenosis.
Courtenay M Holscher (Johns Hopkins Hospital, Baltimore, USA) presented her team’s findings at the 2025 Vascular Annual Meeting (VAM; 4–7 June, New Orleans, USA).
Using 100% Medicare fee-for-service claims data to identify patients who underwent CAS or CEA between January 2017 and December 2024, Holscher and colleagues identified 385,067 carotid revascularisations—45% symptomatic vs. 55% asymptomatic disease, and 77.1% CEA vs. 22.9% CAS.
The proportion of carotid revascularisation procedures performed by vascular surgeons versus other specialties increased from 46% in 2017 to 55% in 2024. Holscher detailed that CEA was mainly performed by vascular surgeons, cardiothoracic surgeons, and general surgeons, and CAS was commonly performed by vascular surgeons, cardiologists and interventional radiologists.
The proportion of carotid revascularisations performed using CAS significantly increased over time (2017: 13% vs. 2024: 37.5%), 25% in symptomatic and 31% in asymptomatic patients. Holscher reported a slight decrease in CEA use after the expansion of CAS in 2023, but this was not found to be statistically significant.
“The utilisation of stenting has significantly increased over time and it’s quite reassuring that there is an increasing share of vascular surgeons performing these revascularization procedures,” said Holscher. “It’s difficult to see how the CMS-required ‘shared decision-making’ discussion between CEA and CAS procedures can realistically occur when a physician cannot offer both procedures.”
