Carotid Revascularization Procedures and Perioperative Outcomes: A Multistate Analysis, 2007-2014

To compare in-hospital mortality, postoperative stroke, and combined stroke/mortality in carotid artery stenting (CAS) patients and carotid endarterectomy (CEA) patients.

Retrospective observational study using data from the State Inpatient Database, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality.

All coded CAS or CEA hospitalizations from 2007 to 2014 in California, Florida, New York, Kentucky, and Maryland.

A total of 198,120 patients, 18 years of age or older, undergoing CAS or CEA.

None.

Primary outcomes of the study were unadjusted rates and adjusted odds of in-hospital mortality, postoperative stroke, postoperative cardiovascular complications, and combined stroke/mortality, before and after correcting for confounders, following either CEA or CAS. In multivariate logistic regression analyses, in each successive individual year, CAS was associated with higher odds of in-hospital mortality (odds ratio [OR] ≥1.5 and p < 0.05), postoperative stroke (OR ≥1.4 and p < 0.05), and combined stroke/mortality (OR ≥1.5 and p < 0.05). Similar significant results were obtained when multivariate logistic regression was stratified by symptomatology. Carotid artery stenting was associated with higher odds of cardiovascular complications in 2012 (OR = 1.5, p < 0.05) and lower odds in 2009 (OR = 0.8, p < 0.05).

This study associated carotid stenting, as compared to endarterectomy, with an increased risk of dying and/or stroke. These associations persisted after statistical adjustment for patient demographics, comorbidities, and symptomatology, as well as after post-stratification by patient symptomatology. Despite this study's large, representative sample and well-defined a priori statistical methods, further research into real-world revascularization outcomes with longer-term follow-up is needed to formulate treatment guidelines.