Dec 14 2010
To meet reimbursement criteria, candidates for carotid artery stenting (CAS) 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, MA, reimbursement criteria may bias comparisons of CAS and carotid endarterectomy (CEA).
In the December issue of the official publication of the Society for Vascular Surgery®, the Journal of Vascular Surgery®, Marc. L. Schemerhorn, MD, reported that he and fellow researchers wanted to evaluate mortality and stroke following CAS and CEA stratified by medical high-risk criteria.
"We gathered data from The Nationwide Inpatient Sample between 2004-2007 and identified 56,564 CAS patients and 482,394 CEA patients, all who had a diagnosis of carotid artery stenosis," said Dr. Schemerhorn. "Medical high-risk criteria were identified for each patient including those undergoing a coronary artery bypass and/or valve repair (CABG/V) during the same admission. Symptom status was defined by history of stroke, transient ischemic 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 CAS than CEA, and stroke was higher in both risk groups after CAS. Patients undergoing CAS were more likely to be symptomatic than those undergoing CEA (13.1 percent vs. 9.4 percent).
Combined stroke or death was higher after CAS for both high-risk patients (asymptomatic 1.5 percent vs. 1.2 percent and symptomatic 14.4 percent vs. 6.9 percent) and non-high-risk patients (asymptomatic 1.8 percent vs. 0.6 percent), symptomatic 11.8 percent vs. 4.9 percent).
CABG/V was performed less commonly with CAS than CEA (2.8 percent vs. 4.0 percent). The combined stroke or death for patients undergoing CABG/V during the same admission was similar for CAS and CEA (4.8 percent vs. 3.2 percent).
Multivariate predictors of combined stroke or death adjusted for age and gender included CAS vs. CEA (odds ratio (OR 2.4), symptom status (OR 6.8), high risk (OR 1.6) and earlier year of procedure (OR 1.1).
Dr. Schemerhorn added that even though this study found that CAS has a higher risk of stroke and death than CEA after adjustment for medical high-risk criteria, further analysis with prospective assessment of risk factors is needed to guide appropriate patient selection for CEA and CAS in the general population. "As more randomized trials compare the efficacy of CAS relative to CEA, 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 revascularization method in those with specified high-risk criteria."
SOURCE Society for Vascular Surgery