Carotid Artery Stenting Group Research Articles

055 * SIMULTANEOUS HYBRID CAROTID STENTING AND CORONARY BYPASS SURGERY VERSUS CONCOMITANT OPEN CAROTID AND CORONARY BYPASS SURGERY: A PILOT FEASIBILITY STUDY

OBJECTIVES: Concomitant carotid and cardiac surgery carries an increased perioperative morbidity and mortality risk. Whether the hybrid procedure of carotid artery stenting (CAS) and coronary bypass surgery decreases the risk of stroke and other complications is still unknown. The aim of this study was to assess early outcomes after simultaneous hybrid CAS and coronary bypass grafting versus open concomitant carotid and coronary bypass surgery. METHODS: We included 20 patients in this study. According to the protocol, all the patients were divided into two groups: Group 1 (10 patients) with hybrid CAS and coronary bypass surgery and Group 2 (10 patients) with concomitant carotid and coronary surgery. Different preoperative, intraoperative and postoperative variables were compared. The primary end point was combined incidence of stroke and death 30 days after surgery or during initial hospitalization. The secondary end points were myocardial infarction, atrial fibrillation, blood loss and need for blood transfusion and duration of intensive care unit and hospital stay. RESULTS: Groups 1 and 2 were similar in preoperative characteristics including age (65.3 ± 6.8 vs 70.7 ± 7.0, P= 0.191) New York Heart Association class (2.3 ± 0.5 vs 1.8 ± 0.7, P= 0.218), EuroSCORE (2.8 ± 2.0 vs 3.6 ± 2.3, P= 0.547), the degree of carotid stenosis (79 ± 12 vs 87 ± 13%, P= 0.224) and average left ventricular ejection fraction (44.3 ± 12.4 vs 43.4 ± 13.3%, P= 0.896). Also, the groups did not differ in intraoperative variables with an exception of extracorporeal circulation time (65.7 ± 14.1 vs 90.0 + 17.4 min, P= 0.023), which was significantly shorter in Group 1. Although rare, and without significant difference, primary end point occurred only in Group 2 (1 stroke and 1 death, 20%). There was no difference in the duration of mechanical ventilation, need for transfusion and duration of intensive care unit and hospital stay between the two groups. CONCLUSIONS: Although limited by a small sample size, our results show that the hybrid procedure of carotid stenting and coronary surgery might be a good therapeutic option but further extended studies are needed to assess its real value.

Comparison of Carotid Artery Stenting and Carotid Endarterectomy in Patients with Symptomatic Carotid Artery Stenosis: A Single Center Study

Carotid artery stenting (CAS) is believed to be an alternative to carotid endarterectomy (CEA); however, recent studies have demonstrated an increase of complications with stenting that does not reflect our experience. We thus wanted to compare the periprocedural and 1-year follow-up outcomes of CAS with those of CEA among patients with symptomatic extracranial carotid stenosis in a population from eastern Turkey. The hospital records of all patients who underwent carotid artery revascularization were retrospectively reviewed. Patients were divided into two groups based on the type of carotid revascularization performed, namely CEA or CAS. Comparisons were made with respect to 30-day and 1-year outcomes of transient ischemic attack (TIA), myocardial infarction (MI), stroke, and all-cause death rates. Composite endpoints for both groups were also analyzed. Thirty-two CEA and 33 CAS procedures were performed for symptomatic occlusive carotid disease. Baseline characteristics were similar between both groups except for the incidence of diabetes mellitus. No significant differences were found with respect to 30-day mortality, MI, and neurologic morbidity endpoints for CEA and CAS procedures. In the postprocedural 1-year follow-up, only TIA was observed to be significantly higher in the CAS group; the other endpoints did not differ significantly. One-year composite endpoints did not differ between both groups (log-rank P = 0.300). In our trial of patients with symptomatic carotid artery stenosis, no significant difference could be shown in periprocedural outcomes, postprocedural outcomes except TIA, and in composite endpoints between the CEA and CAS groups. CAS is a safe and efficacious alternative for the treatment of symptomatic carotid artery stenosis.

Effects of carotid artery stenting on cognitive function in patients with mild cognitive impairment and carotid stenosis.

Carotid stenosis is known to be an independent risk factor in the transformation process of mild cognitive impairment (MCI) to dementia and is treated by carotid artery stenting (CAS); however, the effects of CAS on cognitive function are unclear. In this study, 240 patients were prospectively assigned to a CAS or control group according to patient preference and underwent detailed neuropsychological examinations (NPEs) before and 6 months after treatment. Cerebral perfusion was assessed with computed tomography perfusion (CTP). Among the 240 patients included in the study, 208 patients completed NPEs at baseline and 6 months after therapy. The patients in the two groups did not differ with regard to baseline characteristics, educational level, vascular risk factors (VRFs) and NPEs prior to therapy. Significant improvements in the Mini-Mental State Examination (MMSE; before, 24.6±1.7 vs. after, 24.8±1.9; P=0.016), Montreal Cognitive Assessment (MOCA; before, 23.7±1.7 vs. after, 24.1±2.0; P=0.006), Fuld Object Memory Evaluation (FOME; before, 13.8±2.2 vs. after, 14.0±2.3; P=0.031) and Wechsler Adult Intelligence Scale-digital span (WAIS-DS; before, 6.7±2.1 vs. after, 6.9±2.3; P=0.040) were observed in the CAS group; however, improvements were not observed in the control group. Of the 84 patients in the CAS group who received CTP follow-up, 72 (86%) presented improvements in ipsilateral brain perfusion 6 months after the procedure; however, no improvement was observed in the control group. Close correlations were identified between the change in perfusion and the change in MMSE (r=0.575) and MOCA (r=0.574). CAS improves global cognitive function in patients with carotid stenosis and MCI and the improvement of cognition is closely related to the improvement of cerebral perfusion.

A meta-analysis of carotid endarterectomy versus stenting in the treatment of symptomatic carotid stenosis

Background Carotid stenosis is one of the common reasons for patients with ischemic stroke, and the two invasive options carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the most popular treatments. But the relative efficacy and safety of the methods are not clear. Methods About 521 articles related to CAS and CEA for carotid stenosis published in 1995-2011 were retrieved from MEDLINE, Cochrane Library (CL), and China National Knowledge Infrastructure (CNKI) China Journal Full-Test database. Of them, eight articles were chosen. Meta-analysis was used to assess the relative risks. Results The eight studies included 3873 patients with symptomatic carotid artery stenosis, including 1941 cases in the carotid stent angioplasty group, and 1932 cases in the carotid endarterectomy group. Fixed effect model analysis showed that within 30 days of incidence of all types of strokes, surgery was significantly highly preferred in CAS patients (CAS group) than the CEA patients (CEA group), and the difference was statistically significant (relative ratio (RR)=1.80, 95% confidence interval (CI): 1.380-2.401, P<0.0001). But the incidence of death in the two groups is not showed and is not statistically significant after 30 days (RR=1.52, 95% CI: 0.82-2.82, P=0.18). The rate of cranial nerve injury in the CAS group is lower than the CEA group (RR=0.14, 95% CI: 0.05-0.43, P=0.0005). The incidence of CAS patients with myocardial infarction is lower than the CEA group after 30 days, but statistically meaningless (RR=0.22, 95% CI: 0.05-1.02, P=0.05). The stroke or death in CAS patients were higher than the CEA group after 1 year of treatment ((RR=2.58, 95% CI: 1.03-6.48, P=0.04). Conclusions Compared to CAS, carotid endarterectomy is still the preferred treatment methodology of symptomatic carotid artery stenosis. Future meta-analyses should then be performed in long-term follow-up to support this treatment recommendation.

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

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.

Long-term prognosis after revascularization therapy in patients with atherothrombotic stroke

Many guidelines recommend carotid endarterectomy (CEA) in symptomatic patients with carotid stenosis of greater than 70%, and carotid artery stenting (CAS) as an alternative to CEA. In our study, we evaluated the clinical characteristics of patients who underwent revascularizaton therapy. We reviewed the files of 2369 patients with stroke followed in our cerebrovascular outpatient clinics since 1996. 92 patients were treated by revascularization therapy. A total of 41 patients had CEA, 42 patients had CAS, and 9 patients had vertebral artery stenting; and 77 patients were followed-up for a mean period of 50.2+42.7 months (6 to 168 months). Recurrent stroke or TIA and deaths due to cerebrovascular diseases were similar between CEA and CAS patients. Myocardial infarction (including silent MI) and deaths due to cardiovascular diseases were more common in CAS group, though not significant. The deaths due to other diseases and other non-fatal complications were significantly more common in CEA patients. On the other hand, restenoses - all of which were radiological findings but asymptomatic - were more common in the CAS group. In this study we disclosed neither morbidity nor mortality discrepancies in long term among the patients who were treated with carotid endarterectomy (CEA) and carotid artery stenting (CAS).

Quantitative evaluation using the plaque/muscle ratio index panels predicts plaque type and risk of embolism in patients undergoing carotid artery stenting

ObjectiveWe sought to use a magnetic resonance (MR) plaque imaging technique to establish the plaque/muscle ratio (PMR) index panel to identify vulnerable plaques in subjects undergoing carotid artery stenting (CAS). MethodsBetween 2008 and 2010 we treated 69 patients (71 lesions) by elective carotid endarterectomy (CEA) and 35 patients (36 lesions) by CAS. All patients underwent preoperative MR plaque imaging and the ratio of plaque signal intensity to the sternocleidomastoid muscle was calculated. In the CEA group, we categorized the histopathological findings made on the surgical specimens. In the CAS group, we assessed the post-procedure diffusion-weighted images. ResultsPMR index panels for each plaque type were created using the cut-off value obtained from the receiver operating characteristic (ROC) curves of each plaque type. The probability of each of the four plaque types on each panel was assessed by Fisher's exact test. Multinomial logistic regression analysis of the DWI-positive findings determined significant probability (p=0.042). ConclusionThe results of this study suggest quantitative evaluation using the PMR index panel has a probability to predict both the plaque type and risk of embolism in patients being considered for treatment with CAS.

The risk of carotid artery stenting compared with carotid endarterectomy is greatest in patients treated within 7 days of symptoms

Among patients with symptomatic carotid artery stenosis, carotid artery stenting (CAS) is associated with a higher risk of periprocedural stroke or death than carotid endarterectomy (CEA). Uncertainty remains whether the balance of risk changes with time since the most recent ischemic event. We investigated the association of time between the qualifying ischemic event and treatment (0-7 days, 8-14 days, and >14 days) with the risk of stroke or death within 30 days after CAS or CEA in a pooled analysis of data from individual patients randomized in the Endarterectomy vs Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial, the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) trial, and the International Carotid Stenting Study (ICSS). Data were analyzed with a fixed-effect binomial regression model adjusted for source trial. Information on time of qualifying event was available for 2839 patients. In the first 30 days after intervention, any stroke or death occurred significantly more often in the CAS group (110/1434 [7.7%]) compared with the CEA group (54/1405 [3.8%]; crude risk ratio, 2.0; 95% confidence interval, 1.5-2.7). Patients undergoing CEA within the first 7 days of the qualifying event had the lowest periprocedural stroke or death rate (3/106 [2.8%]). Patients treated with CAS in the same period had a 9.4% risk of periprocedural stroke or death (13/138; risk ratio CAS vs CEA: 3.4; 95% confidence interval, 1.01-11.8; adjusted for age, sex, and type of qualifying event). Patients treated between 8 and 14 days showed a periprocedural stroke or death rate of 3.4% (7/208) and 8.1% (19/234), respectively, for CEA and CAS. The latest treatment group had 4% complications in the CEA group (44/1091) and 7.3% in the CAS group (78/1062). The increase in risk of CAS compared with CEA appears to be greatest in patients treated within 7 days of symptoms. Early surgery might remain most effective in stroke prevention in patients with symptomatic carotid artery stenosis.

Carotid Plaque Characterization by Virtual Histology Intravascular Ultrasound Related to the Timing of Carotid Intervention

To determine the incidence of vulnerable plaques characterized by virtual histology intravascular ultrasound (VH IVUS) in patients with severe internal carotid artery (ICA) stenosis and its relationship to the timing of protected carotid artery stenting (CAS). The study included 141 patients (119 men; mean age 66.9 ± 9 years) with severe ICA stenosis undergoing CAS with cerebral protection. Patients were classified in 3 groups: 39 symptomatic early CAS (<14 days from clinical symptoms); 58 symptomatic delayed CAS (range 15-180 days), and 44 asymptomatic CAS. Culprit plaque component was evaluated by VH IVUS. A vulnerable plaque was defined by a thin-cap fibroatheroma and/or calcified thin-cap fibroatheroma. The composite disabling stroke/mortality was 2.1%. The incidence of vulnerable plaques was significantly higher in the symptomatic early CAS group (25/39, 64.1%) than in the symptomatic delayed CAS group (26/58, 44.8%; p=0.048) or the asymptomatic CAS group (14/44, 31.8%; p=0.003). Symptomatic patients showed a significantly higher incidence of vulnerable plaques (52.6%) than asymptomatic patients (31.8%, p=0.022). There were no significant differences between the symptomatic delayed and asymptomatic groups (p=0.129). By clinical subgroup, a vulnerable plaque was observed in 29 (52.7%) of the patients with 55 transient ischemic attacks, 22 (52.4%) of the 42 minor stroke patients, and 14 (31.8%) of the 44 asymptomatic patients (p=0.152). The incidence of vulnerable plaques was significantly higher in symptomatic patients, increasing as the intravascular study was performed closer to the index ischemic episode.

Effects of carotid artery stenosis treatment on blood pressure

The purpose of this study was to evaluate and compare the long-term effects of carotid endarterectomy (CEA) and carotid artery stenting (CAS) on blood pressure (BP). Between January 2003 and December 2009, 134 patients underwent 145 procedures for treatment of carotid artery stenosis. Patients with at least 1 year of clinical and radiographic follow-up after treatment were included in this study. A total of 102 patients met this criterion and were placed in the CEA group (n = 59) or the CAS group (n = 43) according to their treatment. The percentage change in BP decrement and the number of patients with a normotensive BP were evaluated and compared between the groups. There were no significant differences between the groups with regard to baseline characteristics. Compared with the pretreatment BP, the follow-up BPs were significantly decreased in both groups. At the 1-year followup, the percentage change in the BP decrement was greater in the CAS group (percentage change: systolic BP 9.6% and diastolic BP 12.8%) than in the CEA group (percentage change: systolic BP 5.9% [p = 0.035] and diastolic BP = 8.1% [p = 0.049]), and there were more patients with a normotensive BP in the CAS group (46.5%) than in the CEA group (22.0%, p = 0.012). Both CEA and CAS have BP-lowering effects. Carotid artery stenting seems to have a better effect than CEA on BP at the 1-year follow-up.

Contralateral occlusion is not a clinically important reason for choosing carotid artery stenting for patients with significant carotid artery stenosis

Contralateral carotid artery occlusion by itself carries an increased risk of stroke. Carotid endarterectomy (CEA) in the presence of contralateral carotid artery occlusion has high reported rates of perioperative morbidity and mortality. Our objective was to determine if there is a clinical benefit to patients who receive carotid artery stenting (CAS) compared to CEA in the presence of contralateral carotid artery occlusion. We conducted a retrospective medical chart review over a 4.5-year institutional experience of persons with contralateral carotid artery occlusion and ipsilateral carotid artery stenosis who underwent CAS or CEA. The main outcome measures were 30-day cardiac, stroke, and mortality rate, and midterm mortality. Of a total of 713 patients treated for carotid artery stenosis during this time period, 57 had contralateral occlusion (~8%). Thirty-nine of these patients were treated with CAS, and 18 with CEA. The most common indications for CAS were prior neck surgery (18), contralateral internal carotid occlusion (nine), and prior neck radiation (seven). The average age was 70 ± 8.5 for CEA and 66.7 ± 9.3 for CAS (P = .20). Both groups were predominantly men (CEA 12 of 18; CAS 28 of 39; P = .76), with similar prevalence of symptomatic lesions (CEA 8 of 18, CAS 20 of 39; P = .77). Two patients died within 30 days in the CAS group (5%). No deaths occurred within 30 days in the CEA group (P = .50); the mortality rate for CAS and CEA combined was 3.5%. No perioperative strokes or myocardial infarction occurred in either group. Two transient ischemic attacks occurred after CAS. At mean follow-up of 29.4 ± 16 months (CEA) and 28 ± 14.4 months (CAS; range, 1.5-48.5 months), seven deaths occurred in the CAS group and one in the CEA group (17.9% vs 5.5%; P = .40). There were two reinterventions in the CAS group for in-stent restenosis and there were no reoperations in the CEA group. Although CEA and CAS can both be performed with good perioperative results and acceptable midterm mortality, the observed outcomes do not support use of contralateral carotid artery occlusion as a selection criterion for CAS over CEA in the absence of other indications.

Costs and Cost-Effectiveness of Carotid Stenting Versus Endarterectomy for Patients at Standard Surgical Risk

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated similar rates of the primary composite end point between carotid artery stenting (CAS) and carotid endarterectomy (CEA), although the risk of stroke was higher with CAS, and the risk of myocardial infarction was higher with CEA. Given the large number of patients who are candidates for these procedures, an understanding of their relative cost and cost-effectiveness may have important implications for health care policy and treatment guidelines. We performed a formal economic evaluation alongside the CREST trial. Costs were estimated from all trial participants over the first year of follow-up using a combination of resource use data and hospital billing data. Patient-level health use scores were obtained using data from the SF-36. We then used a Markov disease-simulation model calibrated to the CREST results to project 10-year costs and quality-adjusted life expectancy for the 2 treatment groups. Although initial procedural costs were $1025/patient higher with CAS, postprocedure costs and physician costs were lower such that total costs for the index hospitalization were similar for the CAS and CEA groups ($15 055 versus $14 816; mean difference, $239/patient; 95% CI for difference, -$297 to $775). Neither follow-up costs after discharge nor total 1-year costs differed significantly. For the CREST population, model-based projections over a 10-year time horizon demonstrated that CAS would result in a mean incremental cost of $524/patient and a reduction in quality-adjusted life expectancy of 0.008 years compared with CEA. Probabilistic sensitivity analysis demonstrated that CEA was economically attractive at an incremental cost-effectiveness threshold of $50 000/quality-adjusted life-year gained in 54% of samples, whereas CAS was economically attractive in 46%. Despite slightly lower in-trial costs and lower rates of stroke with CEA compared with CAS, projected 10-year outcomes from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00004732.

Cost-effectiveness of carotid artery stent placement versus endarterectomy in patients with carotid artery stenosis

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated that the risk of the primary composite outcome of stroke, myocardial infarction (MI), or death did not differ significantly in patients with an average surgical risk undergoing carotid artery stenting (CAS) and those undergoing carotid endarterectomy (CEA). However, the cost associated with CAS may limit its broad applicability. The authors' goal in this paper was to determine the cost-effectiveness of CAS with an embolic-protection device versus CEA in patients with moderate to severe carotid artery stenosis who are at average surgical risk. The probability of the primary outcome was obtained from the results of the CREST trial. The quality-adjusted life years (QALYs) associated with each treatment modality were estimated by adjusting for the incidence of each quality-adjusted outcome (QALY weights of ipsilateral stroke, MI, death, and postprocedure QALYs). The total cost associated with each intervention was derived from hospitalization cost and cost associated with primary outcomes including stroke, MI, and death in each group. Costs are expressed in US dollars accounting for inflation up to October 2010. Incremental cost-effectiveness ratios (ICERs) were estimated for the 4-year period after the procedure. All values are expressed as means and 95% confidence intervals. The estimated net costs for patients after treatment with CAS and CEA after consideration of the primary outcome were $18,335 and $13,276, respectively, from the definitive presimulation analysis. Postsimulation values were $19,210 (range $18,264-$20,156) and $14,080 (range $13,076-$15,084), respectively. Overall, QALYs for the CAS and CEA groups were 0.712 and 0.702, respectively (ranging from 0.0 [death] to 0.815 [no adverse events]). The estimated ICER for CAS versus CEA treatment was $229,429. Although the CREST demonstrated equivalent results with CAS (compared with CEA) in patients at average surgical risk with severe carotid artery stenosis, broad applicability of CAS might be limited by the higher cost associated with this procedure.

Complication Rates among Women Receiving Contemporary Carotid Revascularization Procedures (S33.003)

Objective: In the present study we assessed contemporary rates of perioperative complications following carotid artery stenting (CAS) and carotid endarterectomy (CEA) among women. Background Perioperative risks during carotid revascularization procedures in clinical trials are higher among women. Design/Methods: A retrospective chart review was conducted of all carotid revascularization procedures performed at four hospitals in a metropolitan region between June 2009-May2011. Gender differences in choice of revascularization procedures were explored. Rates of combined outcome of in-hospital stroke, clinically significant myocardial infarction and death were assessed. Results: Over 2 years, 483 carotid revascularizations (36.4% CEA and 63.6% CAS) were performed. Women composed 37.1% of the CAS group and 46% of CEA group. Among subjects with asymptomatic stenosis, women were less likely to get CAS (35.8% of CAS group vs. 48% of CEA group were women; p=0.03). Among subjects Conclusions: Gender influences the choice of revascularization procedure among asymptomatic patients and subjects less than 70 years. In spite of advances in contemporary revascularization methods, complication rates among women are quite high; especially in the subgroup of asymptomatic women over 70 years. Disclosure: Dr. Bhattacharya has nothing to disclose. Dr. Damani has nothing to disclose. Dr. Rayes has nothing to disclose. Dr. Chaturvedi has received personal compensation for activities with Genentech, Inc., and Abbott Vascular.

Carotid endarterectomy is more cost-effective than carotid artery stenting

Cost-effectiveness has become an important end point in comparing therapies that may be considered to have clinical equipoise. While controversial, some feel that recent multicenter randomized controlled trials have codified clinical equipoise between carotid endarterectomy (CEA) and carotid artery stenting (CAS). A retrospective analysis of hospital cost and 30-day clinical outcomes was performed on patients undergoing CEA and CAS between January 1, 2008 and September 30, 2010 at a single tertiary referral institution. Cost, not charges, of the index hospitalization was divided into supply, labor, facility, and miscellaneous categories. All costs were normalized to 2010 values. A total of 306 patients underwent either CEA (n = 174) or CAS (n = 132). Mean hospital cost for CAS was $9426 ± $5776 while CEA cost was $6734 ± $3935 (P < .0001). This cost differential was driven by the significantly higher direct supply costs for CAS ($5634) vs CEA ($1967) (P ≤ .0001). The higher costs for CAS were seen consistently in symptomatic, asymptomatic, elective, and urgent subgroups. Patients undergoing CAS who were enrolled in a trial or registry (53.8%) incurred significantly less cost ($7779 ± $3525) compared to those who were not ($11,279 ± $7114; P = .0004). Patients undergoing CEA trended toward a higher prevalence of being symptomatic (44.8%) compared to CAS (34.0%; P = .058). Age was not significantly different between patients undergoing CEA and CAS (70.2 vs 72.0, respectively; P = .36). Coronary artery disease was more common in patients undergoing CAS (60.3% vs 39%; P = .0001). The prevalence of chronic obstructive pulmonary disease, renal failure, hypertension, and diabetes was not significantly different between cohorts. Thirty-day combined stroke/death/myocardial infarction rate was 2.3% (4 of 174) in the CEA group and 3.8% (5 of 132) in the CAS group, P = .5. Overall length of stay (LOS) was 2.1 days in both groups (P = .9). LOS was higher for urgent interventions (7.3-7.5 days) and symptomatic status (2.9-3.5 days) when compared to patients treated electively (1.3-1.4 days). Treatment of carotid disease with CAS was 40% more costly than CEA and did not provide better clinical outcomes or a reduction in LOS. These trends were consistent in symptomatic, asymptomatic, urgent, and elective subgroups At present, CAS cannot be considered a cost-effective treatment for carotid disease.

Treatment for routine, symptomatic, carotid bulb atherosclerosis: Carotid endarterectomy and stenting are comparable.

![Graphic][1] The results of recent carotid artery stenting (CAS) vs carotid endarterectomy (CEA) randomized studies (CREST,1 SPACE,2 EVA3S,3 and ICSS4) have created conflict among surgical and endovascular communities over which procedure is preferred for secondary stroke prevention for symptomatic carotid stenosis. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) established CEA as the gold standard for surgical treatment in the early 1990s. Carotid stenting has been held to the high standard of CEA, and in order to present a viable alternative surgical therapy, it must be effective at preventing strokes, durable, and safe, with complication rates comparable to CEA. Carotid stenting is a clinically effective procedure. CREST, SPACE, and EVA3S showed equivalent annual stroke rates for the 2 treatments in symptomatic patients after the initial 30 days (CEA vs CAS: 0.8 vs 0.6, 1.3 vs 1.4, and 0.7 vs 0.4, percent per year, respectively). The stroke-free survival curves in CREST for CEA and CAS are parallel after the perioperative period out to 4 years, indicating clinical durability. > The increase in minor stroke in the CAS group and the increase in perioperative MI in the CEA group offset one another, leading to the equivalent primary endpoint. Perioperative safety remains the controversial point; the 30-day stroke and death rate for the stented patients was over 2 times that of the surgical group in the EVA3S trial. In the ICSS trial, the CAS group suffered stroke or death twice as often as the CEA group. Complications rates were, at best, equivalent in the 2 groups in the SPACE trial (6.3% for CEA and 6.8% for CAS), with CAS not achieving noninferiority. Why the … [1]: /embed/inline-graphic-1.gif

Treatment for routine symptomatic carotid bulb atherosclerosis

![Graphic][1] Symptomatic internal carotid artery (ICA) stenosis is a common cause of ischemic stroke. The goal of management is to decrease the risk of stroke. This objective can be reached with a combination of medical therapy and revascularization with either carotid endarterectomy (CEA) or carotid artery stenting (CAS). At this time, evidence-based medicine provides guidance for our decision regarding which revascularization procedure is the most appropriate for the patient with routine, symptomatic carotid stenosis, i.e., with no clinical or radiographic exclusions for either procedure. The choice of treatment for revascularization comes down to 3 questions: 1) If the goal is to reduce stroke, which treatment option provides the best short and long-term outcomes? 2) Which treatment is cost-effective? 3) Which treatment provides the best patient-centered outcomes? Two recent trials evaluating the difference between CEA and CAS are the Carotid Revascularization Endarterectomy vs Stent Trial (CREST)1 and the International Carotid Stenting Study (ICSS).2 In CREST, the primary composite endpoint of any stroke, myocardial infarction (MI), or death within 30 days following treatment plus any ipsilateral stroke during long-term follow-up (median 2.5 years) was similar for CAS and CEA (7.2% vs 6.8%, hazard ratio [HR] 1.1, 95% confidence interval [CI] 0.8–1.5). There was no differential treatment effect according to symptomatic status. In contrast, the ICSS interim safety analysis evaluating the 120-day rate of stroke, death, or procedural MI reported that more patients in the CAS group reached the combined endpoint of stroke, MI, or death than the CEA group (8.5% vs 5.2%, HR 1.69, 95% CI 1.16–2.45, p = 0.006).2 In addition, a subanalysis of 231 patients in ICSS underwent MRI and demonstrated more ischemic brain lesions on diffusion-weighted imaging after treatment with CAS than … [1]: /embed/inline-graphic-1.gif

Abstract 3: Restenosis following Carotid Artery Stenting and Endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial

Objectives The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) showed no difference in the composite endpoint of stroke, myocardial infarction, or death between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in patients with symptomatic or asymptomatic carotid stenosis (CS). We compared restenosis or occlusion, and repeat revascularization, between CAS and CEA over 2 years of follow-up. Methods Restenosis, occlusion, and repeat revascularization were assessed at 1, 6, 12 and 24 months post-randomization. Hemodynamically significant restenosis (≥70% diameter reduction) was defined by a peak systolic velocity (PSV) ≥300 cm/second on standardized duplex ultrasonography (DUS), occlusion by an absence of flow within the target artery on DUS, and repeat revascularization by any additional procedure (CEA, angioplasty or CAS) performed on the index artery. Studies were performed in CREST-certified laboratories and interpreted in the CREST Ultrasound Core Lab. Patients included in this report were those who received their assigned treatment within 30 days of randomization and had an ultrasound reviewed at the Core Lab (n=2191). Treatment differences were assessed using proportional hazards models adjusting for age, sex, and symptomatic status. Results In the analytic cohort, 1086 patients received CAS and 1105 received CEA. Over 2 years 113 patients developed restenosis, 56 (rate 5.8%) in the CAS group and 57 (rate 5.8%) in the CEA group; and 8 developed an occlusion, 3 (rate 0.3 %) in the CAS group and 5 (rate 0.5%) in the CEA group. The combined restenosis-occlusion rate was 6.0% (n=58) for CAS and 6.3% (n=62) for CEA (HR=0.90, 95% CI=0.63-1.29, p=0.58). Forty-three patients of the 2191 underwent repeat revascularization (20 CAS, 23 CEA, p=0.69) of which 28 had restenosis by our criteria and so were included ( Figure ). Stroke occurred in 13 (4 CAS; 9 CEA) of the 120 patients with restenosis or occlusion; 1 of the 4 CAS strokes occurred after restenosis was detected, and 5 of 9 CEA strokes occurred after restenosis was detected. Conclusions This analysis of carotid restenosis is the largest reported to date from any randomized clinical trial. Restenosis and occlusion were infrequent and similar up to 2 years following CAS or CEA among 2191 patients. The rates of revascularization likewise did not differ between CAS and CEA. Follow-up out to 10 years is ongoing. Figure. Kaplan-Meier curves of restenosis and occlusion over 2 years.

Abstract 3471: Emergent Carotid Artery Stenting: Outcomes on a National Level

Background: Emergent carotid artery stenting (CAS) is sometimes performed in the setting of acute cerebral ischemia. In this study, we assess outcomes associated with CAS when performed emergently. Methods: A cohort of patients with CAS was identified from the National Inpatient Sample database using the procedure codes (00.63) for the years 2004 through 2007. The type of admission (elective or emergent) for each patient was clarified in the database. Patients with missing admission type were eliminated. We further ascertained the emergent hospitalization by including only patients who were admitted through the Emergency Department. Primary outcomes include stroke (ischemic or hemorrhagic), myocardial infarction or death occurring during the same hospitalization. Multivariate logistic regression analyses were used to assess covariates associated with the primary outcome and hospital mortality. Results: In this analysis, 9001 patients were admitted and treated with CAS; 822 patients (9.13%) had the procedure performed emergently and the rest had elective CAS. The mean age (69.0 ± 13.2 vs. 70.6 ± 10.2) and gender (females 40.4% vs. 39.8%) were similar in both groups. Risk factors included higher rates of congestive failure and chronic lung disease in the emergent group. In addition, emergent CAS had more severe Charlson comorbidity index (4.0% vs. 1.76%; p &lt; 0.0001). Unadjusted analysis showed higher rate of any stroke, myocardial infarction or death in the emergent group (12.3% vs. 3.37%; OR 4.0; 95% CI 3.15, 5.10). Adjusted analysis for the basic demographic, risk factors and the comorbidity index revealed a higher risk of any stroke, myocardial infarction and death when CAS performed emergently (OR 3.27; (95% CI, 2.54, 4.21). Secondary outcomes of hospital mortality (5.11% vs. 0.67%), myocardial infarction (5.47% vs. 1.11%) and intracerebral hemorrhage (2.07% vs. 0.35%) were higher in the emergent CAS group (P &lt; 0.0001). Post-operative stroke rates were similar (1.92% vs. 1.82%; P= 0.85). Intracerebral hemorrhage was the strongest predictor of mortality (OR 64.0; 95% CI 32.1, 127.7). Other predictors of mortality include congestive heart failure, myocardial infarction and the use of thrombolytic. Conclusion: CAS is associated with higher risk of stroke, myocardial infarction and death when performed emergently. Despite the low rate of intracerebral hemorrhage when CAS performed emergently, intracerebral hemorrhage remains the strongest predictor of mortality.

Carotid Endarterectomy is More Cost-Effective Than Carotid Artery Stenting

Carotid Endarterectomy is More Cost-Effective Than Carotid Artery Stenting