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Carotid Artery Stenting Has Higher Post Procedure Stroke and Mortality Rates, and Higher Hospital Charges than Does Carotid Endarterectomy in the U.S. in 2005

James T. McPhee, Andres Schanzer, Louis M. Messina, Mohammad H. Eslami.
University of Massachusetts Medical School, Worcester, Mass.

OBJECTIVES: The role of carotid artery stenting (CAS) in the management of asymptomatic and symptomatic carotid artery stenosis remains uncertain due in part to conflicting results from relatively small clinical studies. Until 2005 no specific ICD-9 procedure code for CAS was available to examine outcomes at a national level. The purpose of this study was to compare the post procedure stroke and mortality rates, length of stay (LOS) and hospital charges after CAS and carotid endarterectomy (CEA) in the United Strates in 2005

METHODS: All patient discharges for carotid revascularization for the year 2005 were identified in the Nationwide Inpatient Sample based on ICD9-CM procedure codes for CEA and CAS The primary outcome measures were in-hospital mortality and postoperative stroke. Secondary outcome measures included total hospital charges and LOS. All statistical analyses were performed using SAS version 9.1 (Cary, NC). Multivariate logistic regression was performed to evaluate independent predictors of postoperative stroke and mortality.

RESULTS: During 2005, an estimated 124,000 patients underwent either CEA or CAS nationally. Overall, 91% of patients underwent CEA (mean age of 71.0 years), while 9% of patients underwent CAS (71.4 years, p=.45) Postoperative stroke rates, in-hospital mortality rates, hospital charges were all higher after CAS [Table 1.] These differences were significantly higher in patients with symptomatic carotid stenosis. LOS although compatible was significantly higher for the symptomatic CAS patients. By logistic regression, CAS was independently predictive of increased mortality (O.R. 1.9; 95% C.I. 1.07-3.32).

CONCLUSIONS: Based on a large representative sample during the 2005, patients undergoing CAS had significantly higher post procedure stroke and mortality rates. Symptomatic patients undergoing CAS had a five fold higher mortality rate than those undergoing carotid endarterectomy. Although this study could not control for case severity, the magnitude of the higher stroke and mortality rates after CAS as currently performed in the U.S. is disturbing. Additionally, patients undergoing CAS had significantly higher hospital charges. If these results are verified in another large U.S. database, a reappraisal of the use of CAS in the U.S. would be warranted.
AUTHOR DISCLOSURES: J.T. McPhee, None; A. Schanzer, None; L.M. Messina, None; M.H. Eslami, None.