Abstract 14764: Potential Heterogeneity in the Performance of Carotid Artery Stenting Relative to Carotid Endarterectomy Among Subgroups of Medicare Beneficiaries in Routine Clinical Practice
Introduction: The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) suggested that the relative performance of carotid artery stenting (CAS) and carotid endarterectomy (CEA) may differ across subgroups of patients defined by age.
Objective: To compare outcomes following CAS relative to CEA in routine clinical practice among subgroups of Medicare patients defined by demographic and clinical characteristics.
Methods: We linked Medicare data (2000-2009) to the Society for Vascular Surgery’s Vascular Registry (SVS-VR; 2005-2008) and to the NCDR® Carotid Artery Revascularization and Endarterectomy Registry (CARE; 2006-2008/9). Medicare patients aged ≥66 years undergoing CAS or CEA were followed from the procedure date for the outcomes of death or a composite endpoint consisting of death, stroke/transient ischemic attack, or peri-procedural myocardial infarction. We compared CAS to CEA using Cox regression in strata of Medicare patients defined by age (≤80/>80), sex, symptomatic status, degree of carotid stenosis (<70%/≥70%), and high-surgical risk status while controlling for other patient- and provider-level factors.
Results: Among 5,254 SVS-VR (1,999 CAS and 3,255 CEA) and 4,055 CARE (2,824 CAS and 1,231 CEA) patients, CAS was associated with increased risk of mortality and the composite endpoint relative to CEA without adjustment. After adjustment, CAS and CEA performance was similar in most subgroups. Adjusted hazards for mortality suggested that CAS and CEA were comparable for patients aged ≤80 (Hazard Ratio [HR] [95% CI] =1.1[0.9-1.4]) or asymptomatic (HR [95% CI]=1.0[0.7-1.3]) but we found a non-significant trend suggesting CAS was associated with higher mortality among patients aged >80 (HR[95% CI]=1.3[1.0-1.8]) and among those with symptomatic carotid stenosis (HR[95% CI]=1.3[1.0-1.7]). Similar patterns were observed for the composite endpoint.
Conclusion: In these exploratory subgroup analyses, we found a non-significant trend suggesting that CEA may be associated with a lower risk of adverse outcomes than CAS in older (>80) and symptomatic patients but that performance did not differ across sex and degree of carotid stenosis subgroups. These results need to be confirmed by further research.
Author Disclosures: J.J. Jalbert: None. L.L. Nguyen: None. M.D. Gerhard-Herman: None. L.A. Williams: None. C. Chen: None. J. Liu: None. H. Kumamaru: None. A.T. Rothman: None. J.D. Seeger: Employment; Modest; Dr. Seeger is a paid consultant to Optum Insight and WHISCON. J.F. Benenati: Consultant/Advisory Board; Modest; Dr. Benenati has served on the advisory board of Abbott, Cordis, Angiodynamics, and Surefire and has served as a consultant for Gore and Cook. P.A. Schneider: Consultant/Advisory Board; Modest; Dr. Schneider has served as a board member of VIVA, 501(c) 3 nonprofit. H.D. Aronow: Other; Modest; Dr. Aronow chairs the SCAI CAS Expert Consensus Document Writing Committee and serves in the Society for Vascular Medicine, the American College of Cardiology (Peripheral Vascular Disease Committee). J.A. Johnston: Employment; Significant; Dr. Johnston is a full-time employee of Eli Lilly and Company.. T.T. Tsai: None. C.J. White: None. S. Setoguchi: Research Grant; Modest; Dr. Setoguchi is supported by a mid-career development award grant K02-HS017731 from the AHRQ, U.S. DHHS. Consultant/Advisory Board; Modest; She also reported receiving research support from Johnson & Johnson and receiving personal income for consulting from Sanofi-Aventis.
- © 2014 by American Heart Association, Inc.