Abstract 13398: Impact of CREST on Carotid Artery Stenting and CEA Utilization in the Dallas/Fort Worth Area

Abstract

Introduction: Carotid endarterectomy (CEA) is a safe and effective way to reduce the ischemic stroke risk in patients with both symptomatic and asymptomatic carotid stenosis. Following the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study in the early 1990s, the number of CEAs performed annually surged. An alternative to this procedure is carotid angioplasty and stenting, which was introduced in 1994. In May 2010, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) compared the overall effectiveness of carotid artery stenting (CAS) versus CEA. CREST is currently considered the definitive study demonstrating the therapeutic equivalence of CEA and CAS. The goal of our study is to compare the incidence of CEA before and after the CREST study in the Dallas-Fort Worth (DFW) area. We hypothesize that the number of CAS procedures has increased since the CREST study. This is the first report to determine the effect of CREST on CAS utilization. Methods: Consecutive cases of intervention for carotid artery stenosis were reviewed before and after CREST using data from the DFW Hospital Council from 7/1/07-7/1/13. The primary endpoint of the study was the number of CEA and CAS performed during Pre-CREST (7/1/07-6/30/10) and Post-CREST (7/1/10-7/1/13). Results: A total of 12021 interventions on patients with carotid stenosis were identified. Pre-CREST there were 4575 CEA and 1060 CAS performed. Post-CREST there were 5250 CEA and 1136 CAS performed. The adjusted p-value comparing the likelihood of undergoing CAS between the two study periods was 0.305. Conclusions: In contrast to previous carotid treatment trials the CREST study has not impacted the utilization CAS in the DFW area. Possible reasons for this include the higher rate of stroke with CAS compared with CEA in CREST, the CMS restrictions on re-imbursement for CAS compared with CEA, limitations in the physician workforce performing CAS, and non-malleable referral patterns that favor the status quo for these two procedures.