Carotid Artery Stenting Has Higher Risks than Carotid Endarterectomy

Newswise — A new study, will be presented at the Vascular Annual Meeting on June 5, 2008 that compares discharge data from patients who had carotid artery stenting (CAS) or carotid endarterectomy (CEA) in 2005. Researchers from the University of Massachusetts Medical School in Worcester, Mass., noted that CAS patients had a much higher risk of postoperative stroke; a five-fold higher in-hospital mortality rates: and increased hospital charges, especially for those patients who had symptomatic carotid stenosis.

Discharge records of approximately 124,000 cases in the United States were reviewed. All patients were mean age 71 years old; 9 percent of patients had CAS and 91 percent underwent CEA. Researchers reported that for symptomatic patients, the comparative in-hospital mortality was 1.3 percent for CEA vs. 5.2 percent for CAS, a significant difference.
Asymptomatic patients’ in-hospital mortality between CEA and CAS were not significantly different (.25 percent and .33 respectively). Postoperative stroke was significantly different in the asymptomatic patients (0.91 percent for CEA vs. 1.58 percent for CAS); it was not significantly different in the symptomatic patients, though the trend was the same (1.84 percent CEA vs. 2.52 percent CAS).

Multivariate logistic regression was performed to evaluate independent predictors of postoperative stroke and mortality; this process showed that CAS was independently predictive of increased mortality. Overall length of stay was significantly lower for CAS patients and asymptomatic patients, but was significantly higher for symptomatic patients having CAS, compared with CEA (6.8 days vs. 5.4 days).

Mean overall charges for hospital stays were $22,800 vs. $35,000 (CEA vs. CAS). When broken down, asymptomatic patients mean costs were $21,700 for CEA and $32,400 for CAS, while costs for symptomatic patients’ costs jumped to $37,000 for CEA and $63,800 for CAS, a significant difference.

“Previous to this study, no specific ICD-9 procedure code was available for CAS, making it difficult to examine outcomes at the national level,” said Mohammad H. Eslami, MD, department of surgery.” The role of CAS in the management of asymptomatic and symptomatic carotid artery stenosis remains uncertain due in part to conflicting results from relatively small clinical studies.”

Dr. Eslami added that although the current research included a large representative sample, the study could not control for case severity, the magnitude of the higher stroke and mortality rates after CAS as currently performed in the United States is disturbing. “If these results, including hospital charges, are verified in another large U.S. database, a reappraisal of the use of CAS in the U.S. would be warranted,” he said.

“Studies such as ours should raise caution about carotid stenting as an ‘equal’ alternative to carotid endarterectomy,” said Dr. Eslami. “At the same time, this study should not be viewed as an indictment of CAS. As an endovascular surgeon who performs CAS based on Centers for Medicare and Medicaid Services guidelines, I believe that CAS should currently be viewed as an extension of therapy available for patients with symptomatic carotid stenosis and not as a replacement. Large multicenter prospective studies eventually will define the rule of CAS in the treatment of patients with carotid stenosis.”

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