title: Comparison of carotid endarterectomy and stenting in real world practice using a regional quality improvement registry.
abstract: OBJECTIVE
  Carotid artery stenting (CAS) vs endarterectomy (CEA) remains controversial and has been the topic of recent randomized controlled trials. The purpose of this study was to compare the practice and outcomes of CAS and CEA in a real world setting.
  
  
  METHODS
  This is a retrospective analysis of 7649 CEA and 430 CAS performed at 17 centers from 2003 to 2010 within the Vascular Study Group of New England (VSGNE). The primary outcome measures were (1) any in-hospital stroke or death and (2) any stroke, death, or myocardial infarction (MI). Patients undergoing CEA in conjunction with cardiac surgery were excluded. Multivariate logistic regression was performed to identify predictors of stroke or death in patients undergoing CAS.
  
  
  RESULTS
  CEA was performed in 17 centers by 111 surgeons, while CAS was performed in 6 centers by 30 surgeons and 8 interventionalists. Patient characteristics varied by procedure. Patients undergoing CAS had a higher prevalence of coronary artery disease, congestive heart failure, diabetes, and prior ipsilateral CEA. Embolic protection was used in 97% of CAS. Shunts were used in 48% and patches in 86% of CEA. The overall in-hospital stroke or death rate was higher among patients undergoing CAS (2.3% vs 1.1%; P = .03). Overall stroke, death, or MI (2.8% CAS vs 2.1% CEA; P = .32) were not different. Asymptomatic patients had similar rates of stroke or death (CAS 0.73% vs CEA 0.89%; P = .78) and stroke, death, or MI (CAS 1.1% vs CEA 1.8%; P = .40). Symptomatic patients undergoing CAS had higher rates of stroke or death (5.1% vs 1.6%; P = .001), and stroke, death, or MI (5.8% vs 2.7%; P = .02). By multivariate analysis, major stroke (odds ratio, 4.5; 95% confidence interval [CI], 1.9-10.8), minor stroke (2.7; CI, 1.5-4.8), prior ipsilateral CEA (3.2, CI, 1.7-6.1), age >80 (2.1; CI, 1.3-3.4), hypertension (2.6; CI, 1.0-6.3), and a history of chronic obstructive pulmonary disease (1.6; CI, 1.0-2.4) were predictors of stroke or death in patients undergoing carotid revascularization.
  
  
  CONCLUSIONS
  In our regional vascular surgical practices, the overall outcomes of CAS and CEA are similar for asymptomatic patients. However, symptomatic patients treated with CAS are at a higher risk for stroke or death.
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA. brian.nolan@hitchcock.org
authors.forename: Brian W
authors.initials: BW
authors.lastname: Nolan
authors.forename: Randall R
authors.initials: RR
authors.lastname: De Martino
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.forename: Andres
authors.initials: A
authors.lastname: Schanzer
authors.forename: David H
authors.initials: DH
authors.lastname: Stone
authors.forename: David
authors.initials: D
authors.lastname: Butzel
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Kwolek
authors.forename: Jack L
authors.initials: JL
authors.lastname: Cronenwett
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000453:epidemiology; D009511:New England; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D058996:Quality Improvement; D012042:Registries; D012189:Retrospective Studies; D015607:Stents; D020521:Stroke / Q000453:epidemiology; D015996:Survival Rate; D016896:Treatment Outcome