Carotid Revascularization Procedures and Perioperative Outcomes: A Multistate Analysis, 2007-2014

Objective: To compare in-hospital mortality, postoperative stroke, and combined stroke/mortality in carotid artery stenting (CAS) patients and carotid endarterectomy (CEA) patients.

Design: Retrospective observational study using data from the State Inpatient Database, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality.

Setting: All coded CAS or CEA hospitalizations from 2007 to 2014 in California, Florida, New York, Kentucky, and Maryland.

Participants: A total of 198,120 patients, 18 years of age or older, undergoing CAS or CEA.

Interventions: None.

Measurements and main results: Primary outcomes of the study were unadjusted rates and adjusted odds of in-hospital mortality, postoperative stroke, postoperative cardiovascular complications, and combined stroke/mortality, before and after correcting for confounders, following either CEA or CAS. In multivariate logistic regression analyses, in each successive individual year, CAS was associated with higher odds of in-hospital mortality (odds ratio [OR] ≥1.5 and p < 0.05), postoperative stroke (OR ≥1.4 and p < 0.05), and combined stroke/mortality (OR ≥1.5 and p < 0.05). Similar significant results were obtained when multivariate logistic regression was stratified by symptomatology. Carotid artery stenting was associated with higher odds of cardiovascular complications in 2012 (OR = 1.5, p < 0.05) and lower odds in 2009 (OR = 0.8, p < 0.05).

Conclusion: This study associated carotid stenting, as compared to endarterectomy, with an increased risk of dying and/or stroke. These associations persisted after statistical adjustment for patient demographics, comorbidities, and symptomatology, as well as after post-stratification by patient symptomatology. Despite this study's large, representative sample and well-defined a priori statistical methods, further research into real-world revascularization outcomes with longer-term follow-up is needed to formulate treatment guidelines.