title: Experience and outcomes with carotid artery stenting: an analysis of the CHOICE study (Carotid Stenting for High Surgical-Risk Patients; Evaluating Outcomes Through the Collection of Clinical Evidence).
abstract: OBJECTIVE
  This study sought to examine operator experience measured by time-related variables on outcomes with protected carotid artery stenting (CAS).
  
  
  BACKGROUND
  Studies on experience have focused on operator and institutional CAS volumes alone in the absence of a better metric.
  
  
  METHODS
  Using the CHOICE (Carotid Stenting for High Surgical-Risk Patients; Evaluating Outcomes Through the Collection of Clinical Evidence) multicenter prospective data from October 1, 2006 to June 1, 2012, 5,841 evaluable subjects were identified. Operator experience within this study was assessed using 5 variables for each operator: 1) baseline CAS volume; 2) time from first CAS to each subsequent CAS; 3) time between each CAS; 4) CAS volume in the institution; and 5) medical specialty (cardiology, surgery, or radiology/neurology). Institutional experience was determined by CAS volume within the study. Embolic protection device dwell time was used to assess technical performance, and 30-day death, stroke, or myocardial infarction composed the clinical outcome. Hierarchical logistic regression and linear mixed models were used.
  
  
  RESULTS
  Cardiologists (p < 0.001) along with operators with longer time interval from first CAS (p < 0.001) had reduced embolic protection device dwell times (technical performance). Increased time interval between CAS was the only independent predictor of 30-day death, stroke, or myocardial infarction (adjusted odds ratio: 1.05, 95% confidence interval: 1.02 to 1.09, p = 0.005). Prolonged embolic protection device dwell time was associated with 30-day death, stroke, or myocardial infarction (adjusted odds ratio: 1.08; 95% confidence interval: 1.01 to 1.17; p = 0.03).
  
  
  CONCLUSIONS
  The time interval between CAS procedures, specialty assignment, and time from first CAS are important measures of operator experience that may significantly affect technical performance and clinical outcome.
authors.affiliation: Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: shishem@ccf.org.
authors.forename: Mehdi H
authors.initials: MH
authors.lastname: Shishehbor
authors.affiliation: Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Sridhar
authors.initials: S
authors.lastname: Venkatachalam
authors.affiliation: Department of Medicine, Center for Interventional Vascular Therapy, Columbia University, New York, New York.
authors.forename: William A
authors.initials: WA
authors.lastname: Gray
authors.affiliation: Wellmont CVA Heart Institute, Kingsport, Tennessee.
authors.forename: Christopher
authors.initials: C
authors.lastname: Metzger
authors.affiliation: Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Brajesh K
authors.initials: BK
authors.lastname: Lal
authors.affiliation: Endovascular Clinical Science Division, Abbott Laboratories, Santa Clara, California.
authors.forename: Lei
authors.initials: L
authors.lastname: Peng
authors.affiliation: Endovascular Clinical Science Division, Abbott Laboratories, Santa Clara, California.
authors.forename: Hend L
authors.initials: HL
authors.lastname: Omran
authors.affiliation: Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality / Q000592:standards; D002983:Clinical Competence / Q000592:standards; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D057505:Embolic Protection Devices; D005260:Female; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality; D016017:Odds Ratio; D018579:Patient Selection; D011358:Product Surveillance, Postmarketing; D011446:Prospective Studies; D019984:Quality Indicators, Health Care; D018570:Risk Assessment; D012307:Risk Factors; D013038:Specialization; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000401:mortality; D013647:Task Performance and Analysis; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
keywords: Dwell time; carotid artery stenting; experience; institutional experience; operator experience