Abstract 7: Has Patient Selection for Carotid Endarterectomy and Stenting changed over time? Carotid revascularization in the postCREST era.
The results of CREST (Carotid Revascularization Endarterectomy versus Stenting Trial), announced in February 2010 added further insight to the issue of patient selection for carotid revascularization. Carotid artery stenting (CAS) was equivalent to carotid endarterectomy (CEA), perhaps better in the younger age group. CEA patients developed more perioperative myocardial infarctions, and CAS patients incurred more perioperative strokes. Our hypothesis was that following the announcement of the CREST results, characteristics of patients undergoing CAS would change to include younger patients and more cardiac disease compared with those undergoing CEA.
Methods: a retrospective chart review was conducted of all carotid revascularization procedures performed at four hospitals in a metropolitan region. The study duration was from June 2009 (8 months prior to CREST) through May 2011 (16 months after CREST). Demographics and high surgical risk criteria were recorded. Comparisons were drawn between patients receiving the procedures prior to and after CREST.
Results: The study included 483 procedures. Of the 174 preCREST procedures, 64(36.8%) were CEA and 110(63.2%) were CAS. Of the 309 postCREST procedures, 112(36.2%) were CEA and 197(63.8%) were CAS. The proportion of patients undergoing CEA for asymptomatic carotid disease did not change significantly (76.6% preCREST vs. 69.6% postCREST: p=0.42). There was a significant increase in the proportion undergoing CAS for asymptomatic disease (52.7% preCREST vs 65.5% postCREST: p=0.04). The patients undergoing CAS for nonspecific symptoms such as dizziness also increased(5.5% preCREST vs. 18.3% postCREST: p=0.002). The median age did not change significantly for either CEA(68.5years preCREST vs. 69.0years postCREST: p=0.95) or CAS(73.0years preCREST vs. 70years postCREST: p=0.23). The proportion of CAS patients ≥70 years somewhat decreased(58.2% preCREST vs.50.3% postCREST: p=0.18). In the CEA subgroup, there was a reduction in the proportion of patients with congestive heart failure (10.9% preCREST vs.2.7% postCREST: p=0.07) and recent myocardial infarction/angina(4.7% preCREST vs.0 postCREST: p=0.06). There was an increase in the proportion of patients undergoing CAS with congestive heart failure(27.3% preCREST vs.37.6% postCREST: p=0.05).
Conclusions: The utilization of CAS for asymptomatic carotid disease and nonspecific symptoms has increased after CREST. There is a trend towards patients with cardiac disease getting CAS more often. In spite of an increased risk of perioperative stroke among the elderly CAS patients, half of the CAS procedures postCREST were performed in subjects ≥70 years. Careful consideration of the choice of carotid revascularization procedures is warranted in the light of the CREST study.
- © 2012 by American Heart Association, Inc.