Establishing a benchmark for performance of carotid artery stenting with outcomes of high risk carotid endarterectomy
Senthil N. Jayarajan, MD, MS1, jeffrey jim, md, mphs2.
1Washington University in St. Louis School of Medicine, Saint Louis, MO, USA, 2Washington University in St. Louis School of Medicine, st louis, MO, USA.
Objectives: The reimbursement for carotid artery stenting (CAS) continues to be limited to patients considered high risk for carotid endarterectomy (CEA). We sought to evaluate the outcomes of high risk (HR) versus standard risk (SR) CEA to develop benchmarks for comparison to developing technologies.
Method: The targeted National Surgical Quality Improvement Program (NSQIP) database from 2012 to 2014 was queried for patients that had CEA as the principal procedure. Patient demographics, comorbidities and procedural outcomes were analyzed. The primary endpoint was a composite of death/stroke/myocardial infarction at 30 days.
Results: There were 9,676 patients identified with 1,474 (15%) with either physiologic and/or anatomic HR criteria. In addition to having a higher prevalence of comorbidities, patients in the HR cohort were more (P<0.0001) likely to be males (66.8% vs 60.6%) and treated on a non-elective basis (20.6% vs 15.9%). The primary endpoint was higher in the HR cohort (8.3% vs 4.6%, P<0.0001). This was also found in the asymptomatic subgroup (7.1% vs 3.6%) and the symptomatic subgroup (9.8% vs. 6.1%, P=0.0004). Overall, HR patients also had a higher rate of the individual endpoints of death, stroke and MI.
Conclusions: One in 6.5 patients undergoing CEA are considered HR. The outcomes of CEA in patients with HR criteria was associated with significantly higher rates of adverse event after CEA. The rates of adverse events were much higher than those recommended by societal guidelines. Alternative technologies with improved results compared to this benchmark should be considered to treat this challenging group of patients.
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