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National Patterns of Carotid Revascularization Before and After the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST)

Educational Objective
To evaluate national patterns in carotid stenting performance in patients older than 70 years in the post-CREST era.
1 Credit CME
Key Points

Question  Given that the Carotid Revascularization Endarterectomy vs Stenting Trial showed slightly better outcome with carotid endarterectomy compared with carotid artery stenting in adults older than 70 years, has there been any decline in carotid artery stenting utilization in patients older than 70 years in the United States after publication of the Carotid Revascularization Endarterectomy vs Stenting Trial in 2010?

Findings  In this population-based analysis of the 2007-2014 Nationwide Inpatient Sample, carotid artery stenting utilization in 494 733 weighted admissions of patients older than 70 years increased steadily at a mean of 6.0% per year, from 10.6% in 2007 to 14.5% in 2012. After multivariable adjustment for patient and hospitalization characteristics, the odds of carotid artery stenting as the method of carotid revascularization in patients older than 70 years increased by 13% when comparing times before (2007-2010) with times after (2011-2014) publication of the Carotid Revascularization Endarterectomy vs Stenting Trial.

Meaning  Contrary to expectations, there has not been any significant decline in carotid artery stenting utilization in adults older than 70 years after publication of the Carotid Revascularization Endarterectomy vs Stenting Trial.

Abstract

Importance  The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) showed greater safety of carotid artery stenting (CAS) in patients younger than 70 years and carotid endarterectomy (CEA) in those older than 70 years. It is unknown how the result of CREST has influenced carotid revascularization choices in the United States.

Objective  To evaluate national patterns in CAS performance in patients older than 70 years in the post-CREST (2011-2014) compared with the pre-CREST (2007-2010) era.

Design, Setting, and Participants  All adults older than 70 years undergoing carotid revascularization in the United States from 2007 to 2014 were retrospectively identified from the 2007-2014 National Inpatient Sample using International Classification of Disease, Ninth Revision procedural codes. From 61 324 882 unweighted hospitalizations contained in the 2007-2014 National Inpatient Sample, 494 733 weighted carotid revascularization admissions in adults older than 70 years were identified using International Classification of Disease, Ninth Revision procedural codes.

Main Outcomes and Measures  The proportion of CAS performed in all age groups over time was estimated and multivariable-adjusted models were used to compare the odds of receiving CAS in the pre-CREST with those in the post-CREST era in adults older than 70 years.

Results  A total of 41.8% of all patients were women, and mean (SE) age at presentation was 78.1 (0.03) years. A total of 16.3% of CAS and 10.1% of CEA procedures were performed in patients with symptomatic stenosis. The proportion of patients older than 70 years receiving CAS increased from 11.9% in the pre-CREST to 13.8% in the post-CREST era (P = .005). In multivariable models, the odds of receiving CAS increased by 13% in all patients older than 70 years in the post-CREST compared with the pre-CREST period (odds ratio [OR], 1.13, 95% CI, 1.00-1.28, P = .04), including symptomatic women (OR, 1.31, 1.05-1.65, P = .02). Symptomatic stenosis (OR 1.39; 95% CI, 1.27-1.52; P < .001), congestive heart failure (OR, 1.48; 95% CI, 1.35-1.63; P < .001), and peripheral vascular disease (OR, 1.35; 95% CI, 1.27-1.43; P < .001) were associated with higher odds of CAS; comorbid hypertension (OR, 0.70; 95% CI, 0.66-0.74; P < .001), smoking (OR, 0.84; 95% CI, 0.78-0.91; P < .001), and weekend admission (OR, 0.77; 95% CI, 0.68-0.88; P < .001) were negatively associated with the odds of CAS.

Conclusions and Relevance  Despite concerns for higher periprocedural complications with CAS in elderly patients, the odds of CAS increased in the post-CREST compared with pre-CREST era in patients older than 70 years, including symptomatic women.

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Article Information

Accepted for Publication: September 8, 2017.

Corresponding Author: Fadar Oliver Otite, MD, ScM, Department of Neurology, C215, University of Miami Miller School of Medicine, 1120 NW 14th St, Miami, FL 33136 (oliverotite@gmail.com).

Published Online: December 4, 2017. doi:10.1001/jamaneurol.2017.3496

Author Contributions: Dr Otite had full access to all of the study data and takes responsibility for the integrity and accuracy of the data analysis.

Study concept and design: Otite, Malik, Chaturvedi.

Acquisition, analysis, or interpretation of data: Otite, Khandelwal, Chaturvedi.

Drafting of the manuscript: Otite.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Otite.

Administrative, technical, or material support: Khandelwal, Malik.

Study supervision: Khandelwal, Malik, Chaturvedi.

Conflict of Interest Disclosures: Dr Chaturvedi serves on the executive committee of the Carotid Revascularization Endarterectomy vs Stenting Trial 2 and Asymptomatic Carotid Trial 1 studies. No other disclosures are reported.

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