Comparative effectiveness of carotid revascularization therapies: evidence from a National Hospital Discharge
Robert J McDonald1, Jennifer S McDonald2, Terry M Therneau2
1From the Department of Radiology (R.J.M., J.S.M., D.F.K., H.J.C.), Department of Biostatistics (T.M.T.), and Department of Neurosurgery, College of Medicine (G.L., D.F.K., H.J.C.), Mayo Clinic, Rochester, MN. mcdonald.robert@mayo.edu.
Insights
Carotid angioplasty and stenting (CAS) showed higher risks of death, stroke, and poor outcomes than carotid endarterectomy (CEA). This was observed in both symptomatic and asymptomatic patients undergoing carotid revascularization.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Health Services Research
Background:
- The clinical effectiveness of carotid endarterectomy (CEA) versus carotid angioplasty and stenting (CAS) remains debated.
- Large-scale comparative outcome data are crucial for guiding treatment decisions.
Purpose of the Study:
- To compare the safety and efficacy of CEA and CAS in a real-world setting.
- To evaluate adverse outcomes associated with each revascularization strategy using propensity score matching.
Main Methods:
- Retrospective analysis of the 2006-2011 Premier Perspective Database.
- 1:1 propensity score matching of 12,002 CEA and 12,002 CAS procedures using 33 covariates.
- Comparison of primary composite endpoint (mortality, stroke, myocardial infarction) and modified endpoint (excluding myocardial infarction).
Main Results:
- CAS was associated with significantly higher risks of the primary composite endpoint in both asymptomatic (OR 1.40) and symptomatic (OR 2.31) patients.
- Similar increased risks were observed for the modified composite endpoint (asymptomatic OR 1.49, symptomatic OR 3.02).
- No significant difference in acute myocardial infarction risk between CEA and CAS.
Conclusions:
- Carotid angioplasty and stenting (CAS) is linked to increased perioperative risks, including mortality and stroke, compared to carotid endarterectomy (CEA).
- These findings apply across all patient ages and clinical presentations, suggesting CEA may be preferable in many cases.
- The study highlights potential safety concerns with CAS in a large, diverse patient population.
Background And Purpose:
Clinical equipoise of carotid revascularization therapies remains controversial. We sought to determine whether adverse outcomes after carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS) were similar using propensity score-matched analysis of retrospective data from a large hospital discharge database.
Methods:
All CEA and CAS cases were identified from the 2006 to 2011 Premier Perspective Database and subjected to 1:1 propensity score matching using 33 clinical covariates associated with carotid revascularization. A primary composite end point of peri- or postoperative mortality, stroke, or acute myocardial infarction and a modified composite end point excluding acute myocardial infarction were used to compare our findings with recent prospective controlled trials. Multivariate regression and Cox-proportional hazard ratio survival analysis were performed to compare revascularization therapy outcomes.
Results:
After 1:1 propensity score matching, 24 004 (12 002 CEA and CAS) asymptomatic and 3506 (1753 CEA and CAS) symptomatic procedures were included. The risk of the primary composite end point was significantly higher after CAS than CEA in both asymptomatic (odds ratio, 1.40 [1.19-1.65]; P<0.0001) and symptomatic (odds ratio=2.31 [1.78-3.00]; P<0.0001) presentations, irrespective of age (P=0.28) or sex (P=0.35). Similar findings were observed using the modified composite end point for both asymptomatic (odds ratio, 1.49 [1.25-1.78]; P<0.0001) and symptomatic (odds ratio, 3.02 [2.25-4.07]; P<0.0001) presentations. Acute myocardial infarction risk was not significantly different between revascularization therapies, regardless of clinical presentation (P=0.71 and 0.24).
Conclusions:
Among individuals undergoing carotid artery revascularization from a large sample of US hospitals, CAS was associated with higher risk of perioperative mortality, stroke, and unfavorable discharges compared with CEA for all ages and clinical presentations.
