Long Term Comparative Effectiveness of Carotid Stenting Versus Carotid Endarterectomy in a Large Tertiary Care Vascular Surgery Practice
Robert Garvin, Evan Ryer, Andrea Berger, James Elmore.
Geisinger Medical Center, Danville, PA, USA.
Objectives: Carotid interventional trials have strict inclusion and exclusion criteria that make translation of their results to the real-world population challenging. In routine clinical practice the role of clinical decision making is difficult to evaluate. We designed this trial to compare the effectiveness of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in a real-world setting.
Methods: A retrospective study was performed of all consecutive patients undergoing (CAS) and (CEA) performed only by Vascular Surgeons in a large rural tertiary health care system from 2004 to 2014. Post-operative outcomes of stroke, acute myocardial infarction (AMI), and death were analyzed at 30-days and over the long term (median follow up: CAS 4.8 years and CEA 5.5 years). Standard statistical analysis was performed. Differences in long term outcomes were expressed as cumulative incidence functions for stroke and AMI which account for the high death rate in this vascular patient population, and as Kaplan-Meier curves for death itself.
Results: From January 1, 2004 through December 31, 2014, there were 2331 carotid interventions performed (CAS=478, CEA=1853), all by fellowship-trained vascular surgeons. Average patient age was 71 years, and 63% were male. Pre-operatively 30% of patients were symptomatic, and 77% of patients had high grade stenosis in the 70-99% range. CEA patients were more likely to have pre-operative hypertension (89.7% vs 86.2%, p=0.029) and were less likely to have a history of cardiovascular disease (53.4% vs 59.4%, p=0.018), otherwise the 2 groups were comparable. There were no significant differences in 30-day outcomes (stroke: CAS 3.1% vs CEA 3.3%, p=0.817; AMI: CAS 1.7% vs CEA 2.2%, p=0.474; death: CAS 0.6% vs CEA 0.7%, p=0.859) or long term outcomes (stroke: CAS 35.6% vs CEA 33.6%, p=0.202; AMI: CAS 21.0% vs CEA 22.7%, p=0.886; death: CAS 28.2% vs CEA 28.4%, p=0.122).
Conclusions: The short and long term outcomes after CAS versus CEA are similar when performed in a real-world setting by fellowship trained vascular surgeons whose clinical acumen is required when deciding which procedure to offer patients.
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