To meet reimbursement criteria, candidates for carotid artery stenting must either be high-risk surgical patients or be enrolled in a critical trial. According to researchers from the Beth Israel Deaconess Medical Center’s Division of Vascular Surgery in Boston, USA, reimbursement criteria may bias comparisons of stenting and carotid endarterectomy.
In the December issue of the Journal of Vascular Surgery, Marc Schermerhorn reported that he and fellow researchers wanted to evaluate mortality and stroke following carotid artery stenting and carotid endarterectomy stratified by medical high-risk criteria.
“We gathered data from The Nationwide Inpatient Sample between 2004–2007 and identified 56,564 carotid artery stenting patients and 482,394 carotid endarterectomy patients, all who had a diagnosis of carotid artery stenosis,” said Schemerhorn. “Medical high-risk criteria were identified for each patient including those undergoing a coronary artery bypass and/or valve repair during the same admission. Symptom status was defined by history of stroke, transient ischaemic attack and/or amarosis fugax. The primary outcome was postoperative death, stroke and combined stroke or death, stratified by high-risk vs. non-high-risk status and symptom status.”
In high and low-risk patients, mortality was higher after stenting than endarterectomy, and stroke was higher in both risk groups after stenting. Patients undergoing stenting were more likely to be symptomatic than those undergoing endarterectomy (13.1% vs. 9.4%).
Combined stroke or death was higher after stenting for both high-risk patients (asymptomatic 1.5% vs. 1.2% and symptomatic 14.4% vs. 6.9%) and non-high-risk patients (asymptomatic 1.8% vs. 0.6%, symptomatic 11.8% vs. 4.9%).
Coronary artery bypass and/or valve repair was performed less commonly with carotid artery stenting than endarterectomy (2.8% vs. 4%). The combined stroke or death for patients undergoing coronary artery bypass and/or valve repair during the same admission was similar for stenting and endarterectomy (4.8% vs. 3.2%).
Multivariate predictors of combined stroke or death adjusted for age and gender included stenting vs. endarterectomy – odds ratio (OR 2.4), symptom status (OR 6.8), high risk (OR 1.6) and earlier year of procedure (OR 1.1).
Schermerhorn added that even though this study found that carotid artery stenting has a higher risk of stroke and death than endarterectomy after adjustment for medical high-risk criteria, further analysis with prospective assessment of risk factors is needed to guide appropriate patient selection for endarterectomy and stenting in the general population. “As more randomised trials compare the efficacy of stenting relative to endarterectomy, additional population-based analyses with well-defined high-risk criteria are needed to be certain that acceptable results are obtainable in the general population. Further work also is needed to define the appropriate role of either revascularisation method in those with specified high-risk criteria.”
Source: Society for Vascular Surgery
