November 25, 2008 - Stenosis of the carotid artery may lead to a stroke or transient ischemic attack (TIA), often called a “mini-stroke, and several large, multi-center randomized trials in the 1990s found carotid endarterectomy (CEA) surgery is an effective procedure for preventing stroke when the degree of stenosis is more than 60 percent.
While CEA remains the procedure of choice for patients with severe carotid artery stenosis, carotid artery stenting (CAS), an endovascular procedure, is sometimes offered to older patients or when the narrowed artery is inaccessible. Stenting also is used for individuals who are at risk for complications such as neurological conditions, prior surgery or exposure to radiation.
Research has been published about CEA and CAS, however there was no specific discharge code for CAS until 2005. With discharge data from 20 percent of all U.S. nonfederal non-acute hospitals now available from the Nationwide Inpatient Sample, researchers from the University of Massachusetts at Worcester wanted to compare the benefits of both procedures for that same year, as well as examine surgical outcomes and resource utilization associated with CAS and CEA. Researchers believe this is the first study to use this data when comparing both procedures. The complete study is available in the December 2008 issue of the Journal of Vascular Surgery, published by the Society for Vascular Surgery.
“Our primary outcome measures of interest were in-hospital mortality and postoperative stroke,” said senior author Mohammad H. Eslami, M.D., division of vascular and endovascular surgery. “We also reviewed comorbidities, postoperative complications, length of hospital stay and charges, and resource utilization”
“During 2005 an estimated 135,701 patients underwent either CEA or CAS nationally and approximately 91 percent had CEA,” said Dr. Eslami. “We identified 124,000 patients who had carotid revascularization procedures. Almost all of the CAS patients had no symptoms (such as a prior TIA) for carotid artery narrowing. However, those who had CAS had a four-fold increase in mortality and an almost two-fold increase in postoperative stroke compared with those who had CEA.”
Researchers said that mean charges for CAS patients were $35,100, which was significantly higher than CEA patients at $22,800. However these costs were much more pronounced when those with symptoms were evaluated, where the charges were $37,000 for CAS and $63,800 for CEA patients (who had higher odds of postoperative stroke and mortality).
Dr. Eslami said that CEA has clearly significant advantages over stenting in preventing postoperative complications or death and should remain the first choice in patients who require carotid artery revascularization.
“This study is not an indictment for CAS technology,” said Dr. Eslami. “I believe stenting will play an important role in carotid revascularization once the role of the procedure is better defined. Carotid stenting should be performed very cautiously and selectively and at specialized centers where both procedures are performed with great results.”
Dr. Eslami added that randomized controlled trials with homogenous symptomatic and asymptomatic patient groups should be performed to define the role of CAS and determine its future applications in patients with carotid artery stenosis. The researchers explained that over time the outcome gap between CAS and CEA may grow smaller as technical improvements are made along with patient selection.
For more information: www.jvascsurg.org, www.VascularWeb.org