Outcomes of carotid artery stenting and endarterectomy in the United States

Abstract

Objectives: With the evolution of endovascular techniques, carotid artery stenting (CAS) has been compared to carotid endarterectomy (CEA). Several studies have reported inferior results with CAS in the elderly. The objective of this study was to evaluate national outcomes of CAS and CEA and to compare utilization and outcomes of these procedures in different age groups.

Methods: We evaluated the 2005 Nationwide Inpatient Sample for hospitalizations with a procedure of CAS or CEA within 2 days after admission at age 60 years and above. Procedures were analyzed with respect to patient demographics and associated complications.

Results: A total of 80,498 carotid interventions (73,929 CEA and 6,569 CAS) were identified. The overall incidence of stroke was 4.16% after CAS and 2.66% after CEA (P < .0001). CAS was more often utilized in octogenarians than in younger patients (8.55% in 80+ vs 7.92% in 60-69 years; P < .0002). Increased age was not associated with greater stroke rates after CAS or CEA (P = .19 and .06, respectively). Octogenarians, compared to younger patients, had greater cardiac, pulmonary, and renal complications after CEA (3.0% vs 1.9%, 1.9% vs 1.0%, and 1.4% vs 0.54%, respectively; P < .0001). When adjusted by age, gender, complications, and Elixhauser comorbidities, patients after CAS were 1.6 times as likely to have a stroke (confidence interval [CI] = 1.37-1.78) when compared to CEA. Significant predictors of postoperative hospital mortality were stroke (odds ratio [OR] = 29.0; 95% CI = 21.5-39.1), cardiac complications (OR = 6.4; 95% CI = 4.4-9.1), pulmonary complications (OR = 3.5; 95% CI = 2.31-5.19), and renal failure (OR = 2.5; 95% CI = 1.6-3.8). With increasing age, overall mortality steadily increased after CAS (from 0.23% to 0.67%; P = .0409) but remained stable after CEA.

Conclusion: Octogenarians did not have a higher risk of stroke after CAS when compared to younger patients. Stroke was the strongest predictor of hospital mortality. The increased utilization of CAS in the aged, which had significantly higher stroke rates in all age groups studied, may account for the greater hospital mortality seen after CAS in the elderly. Further studies focused on the aged are needed to define the best management strategies in the elderly.