Surgeon's 30-day outcomes supporting the carotid revascularization endarterectomy versus stenting trial.

Abstract

While the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) has been widely accepted as a landmark trial establishing an equivalent risk of major adverse events following carotid endarterectomy (CEA) or carotid artery stenting (CAS), the applicability of these findings to single centers has been questioned owing to the rigid selection criteria for investigators in the study. Although refuted by the findings of a subsequent study, a substudy of CREST established a higher periprocedural stroke rate for CAS when the surgeon was a vascular surgeon. To present our 30-day results of stroke, death, myocardial infarction, and composite major adverse events to determine if a single vascular surgeon's outcomes at our hospital are consistent with the results of CREST. A retrospective analysis of patients with high-grade carotid artery stenosis treated with CEA or CAS by a vascular surgeon at our institution from September 9, 2005, through December 17, 2012, was performed. A χ2 analysis was used to compare the incidence of specific high-risk patient characteristics in each group. The Fisher exact test was used to compare the risks of stroke, death, myocardial infarction, and composite major adverse events between CEA and CAS. These results were then compared with those reported in CREST. A total of 182 cases (94 CAS and 88 CEA) performed by a single vascular surgeon were included for analysis. While in CREST the periprocedural risk of stroke was higher following CAS (4.1% vs 2.3%, P = .01) and the risk of myocardial infarction was higher following CEA (2.3% vs 1.1%, P = .03), there was no significant difference in the incidence of these outcomes between the 2 treatment modalities in our study. When compared with CREST, our rates of myocardial infarction, stroke, death, and composite adverse events (CEA, 4.5% vs 3.4%; P = .79; CAS, 5.2% vs 4.3%; P >.99) were no different. Similar to CREST, the 30-day risk of composite major adverse events was equivalent for the 2 treatment modalities. We attribute our comparable incidence of perioperative stroke with CAS and CEA to improved patient selection. We excluded most patients older than 80 years and those with complex anatomy from consideration for CAS. Our results confirm those of CREST and demonstrate that both CEA and CAS can be performed safely by a vascular surgeon in properly selected patients.