J. Nicklas1, J. Albright1, E. Jerzual1, A. Obi1, P. Henke1 1University Of Michigan,Vascular Surgery,Ann Arbor, MI, USA
Introduction: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) suggested that there was no significant difference between carotid endarterectomy (CEA) and transfemoral carotid artery stenting (CAS) in the endpoint of major adverse cardiovascular events (MACE) including stroke, myocardial infarction, or death but a 2 fold increased risk of stroke with CAS. Limited reports exist in real world hospital outcomes for these procedures.
Methods: 11,290 patients (pts) who underwent CEA and 2,391 pts who underwent CAS in 34 hospitals between 1/3/2012 and 2/28/2018 were assessed for baseline demographics, anatomical variables, medications, and major outcomes, at 30 days. Statistical modeling was done with univariable and multivariable analysis for stroke and MACE.
Results: Demographics in CREST and our population were similar in age (69 vs 70 years), gender (65% vs 60% male), and race (93% vs 93% white). However, in our population, the 30-day incidence of MACE among pts undergoing CEA vs CAS was 2.8% (n=321) vs 5.9%, (n=141), p<0.001 and the incidence of stroke was 2.8% in CEA (n=309) vs 4.4% in CAS (n=105), p<0.001. After multivariable adjustment, CAS was associated with increased stroke risk – (OR = 1.323; 95% confidence interval = 1.018, 1.718, P = .036) and MACE- (1.261; 1.004, 1.584, P = .046) as compared with CEA.
Preoperative risk factors for stroke after CEA included: female gender – (1.33; 1.06-1.67), non-ambulatory status – (1.54; 1.17-2.02), contralateral carotid artery occlusion – (2.19; 1.51-3.17), restenosis of a prior CEA (2.22; 1.21-4.07), prior stroke (2.33; 1.56-3.17), and restenosis of a prior CAS (3.85; 1.31-11.34). Significant perioperative risks of stroke include: non-patch closure – (1.44; 1.03-2.02) and eversion CEA technique – (1.50; 1.02-2.22). 30-day MACE analysis showed that the use of a shunt – (1.28; 1.03-1.59) and renal failure requiring dialysis – (2.44; 1.25-4.74) increased the risk.
Preoperative risk factors for stroke after CAS included: low BMI – (1.06; 1.03-1.10), lack of anemia – (1.56; 1.05-2.57), diabetes – (2.18; 1.43-3.32), and non-white race – (2.25; 1.23-4.10). Significant perioperative risks include: increased operative time – (1.55; 1.23-1.95), embolic protection failure – (1.85; 1.01-3.39), and tracheostomy – (10.35; 1.72-62.33). 30-day MACE factors also included: advanced age – (1.024; 1.01-1.04), lack of Ace/ARB medications – (1.51; 1.05-2.15), >=2 coronary arteries >70% obstructed – (2.60; 1.28-5.27), and left main stenosis >50% – OR 2.84 (1.16-6.91).
Conclusion: Our large multi-hospital real world practice registry suggests that CEA in community practice is associated with better outcomes than transfemoral CAS, and diverges from the CREST results. Differential factors were associated with CEA and CAS risks for stroke and MACE.