Abstract 79: Effect of Carotid Revascularization Endarterectomy Versus Stenting Trial Results on Performance of Carotid Artery Stent Placement and Carotid Endarterectomy in United States

Abstract

Introduction: Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) results, published in 2010, showed no difference in composite outcome (stroke, myocardial infarction, or death) between carotid artery stent placement (CAS) and carotid endarterectomy (CEA). The impact of these results on the pre-existing practices has not been studied. The aim of our study is to determine whether any change in utilization and outcomes of CAS and CEA subsequent to the CREST results. Methods: We estimated the frequency of CAS and CEA procedures in the years 2009 (pre-CREST period) and 2011 (post-CREST period), using data from the National In-patient Sample (NIS). Pre- and post-CREST CAS and post-CREST CEA rates and outcomes were compared with pre-CREST CEA (reference). Results: A total of 225,191 patients underwent CEA or CAS in pre- and post-CREST period. The frequency of CAS did not change after CREST publication. In the pre-CREST period, CAS group (compared with CEA) were younger .Neurological complications, and in-hospital mortality was higher in the CAS group compared to CEA group in the pre-CREST analysis (p=0.008, 0.0003, 0.0004, respectively. In the post-CREST period, the frequency of CAS has remained unchanged in comparison to CEA. Neurological complications were more frequently reported in the post-CREST group (p<0.0001 and 0.005, respectively). Post-procedure cardiac complications were not different in both pre and post CREST CAS group when compared with reference CEA group (p=0.8 and 0.6, respectively). After adjusting for age, gender and risk factors, the Odds ratio (OR) for moderate to severe disability was 1.0 (95% CI 0.8-1.2) in the pre-CREST CAS group and 0.7 (95%CI 0.6-0.9) in the post-CREST CAS group compared with the reference. Adjusted OR for neurological complications in the pre-CREST CAS group was 0.6 (95%CI 0.6-0.9) and 0.7 (95%CI 0.5-0.9) in the post-CREST CAS group. Conclusion: The frequency of CAS and CEA for carotid artery stenosis has not changed after the publication of CREST trial. The demographics, pre-treatment co-morbidity profile and in-hospital complications remain unchanged during the two time periods. CAS continues to have higher risk of post-operative neurological complications as reported in CREST trial.