Abstract TP145: Effect of Carotid Revascularization Endarterectomy Versus Stenting Trial Results on Performance of Carotid Artery Stent Placement and Carotid Endarterectomy

Abstract

Introduction: Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) results, published in 2010, showed no difference in outcome between carotid artery stenting (CAS) and carotid endarterectomy (CEA). We aim to determine whether there has been any change in utilization or outcomes of CAS and CEA after CREST results. Methods: We determined the frequency of CAS and CEA procedures performed in the state of Minnesota, in the years 2009 (pre-CREST period) and 2011 (post-CREST period), using data from the Minnesota Hospital Association. Pre- and post-CREST CAS and post-CREST CEA rates and outcomes were compared with pre-CREST CEA (reference). In-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. Results: A total of 2,718 patients underwent CEA or CAS in pre- and post-CREST period. The frequency of CAS increased from 8.2% to 11.5% of the total patients treated (p=0.004). In the pre-CREST period, CAS group (compared with CEA) were younger, had higher rate of diabetes mellitus and congestive heart failure, in-hospital occurrence of urinary tract infection, sepsis, and myocardial infarction. In the post-CREST period, CAS group did not differ from CEA group in demographics, medical co morbidities, or in-hospital complications except UTI. Hospital stay and hospital charges were greater with CAS compared to CEA, however, the differences in 2011 were less than in 2009. After adjusting for age, sex, relevant risk factors and hospital complications, compared with pre-CREST CEA, pre-CREST CAS was associated with higher neurological complications (odds ratio [OR] 3.3; 95% confidence interval [CI] 1.1-10; p=0.03), cardiovascular complications (OR 5.0; 95% CI 1.8-14; p=0.001), and composite outcome of neurological complications, cardiovascular complications, or death (OR 4.0; 95% CI 1.8-8.6; p=0.0007). There was no difference in outcomes or procedure-related complications between post-CREST CAS and either pre- or post-CREST CEA. Conclusion: There has been a significant increase in the number and improvement in outcome of CAS procedures performed after publication of CREST results in state of Minnesota, presumably due to higher rates of CAS performance in average surgical risk patients.