title: An Observational Registry of Carotid Endarterectomy and Carotid Artery Stenting in Brazil: Study Protocol.
abstract: BACKGROUND
  Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. CEA has been considered the first-line treatment for carotid stenosis worldwide, and the safety and efficacy of CAS compared to CEA remains in question.
  
  
  OBJECTIVE
  The purpose of this study is to compare the practice and outcomes of CAS and CEA in a real-world setting within public university hospitals in Brazil.
  
  
  METHODS
  This study will be a prospective 5-year analysis of treatment for atherosclerotic carotid stenosis with CEA and CAS performed at 5 centers affiliated with the Vascular Study Group at public university hospitals in Brazil. The indications for the procedures will be determined by each surgeon's individual discretion, in accordance with preoperative risk evaluation. The primary outcome measures will be (1) any in-hospital stroke or death, and (2) any per-procedural stroke, death, or myocardial infarction (MI). Patients undergoing CEA in conjunction with cardiac surgery will be excluded from the study. Multivariate logistic regression will be performed to identify predictors of stroke or death in patients undergoing CEA and CAS. All tests of significance will be performed at the .05 level. This study was approved by the Committee of Ethics in Research at the University Hospital of Ribeirao Preto Medical School, and in all other participating institutions linked to National Research System and National Board of Health in Brazil (Process 15695/2011).
  
  
  RESULTS
  This study is currently in the recruitment phase, and the final patient is expected to be enrolled by the end of 2018. We hope to recruit approximately 800 patients to the study. Analyses will focus on primary end points for patients that are allocated to each treatment group. During the per-procedural period, the occurrence of the primary end point components (stroke, MI, or death) for CAS and CEA will be analyzed for symptomatic or asymptomatic subjects.
  
  
  CONCLUSIONS
  The analyses of the primary endpoints (and all others variables of the study) are expected to be published in 2019 in a peer reviewed journal, and results will be presented at scientific meetings, with summary results published online. This study will obtain new data related to the quality of treatment for carotid disease in Brazil at the primary training centers of future vascular surgeons, but the initial data that will be obtained and published (with the outcomes and complications) are restricted to the first 30 days postprocedure. This time restriction limits the comparison of the results that relate to the main goal of treatment, which is to decrease the risk of stroke over 5 years. The purpose of the study group is to continue the monitoring of patient records, and evaluate the follow-up data in the 5 years following the initial evaluation. This study protocol will contribute very significantly to improving the care of patients with carotid disease, in addition to qualifying the level of assistance provided in public university hospitals in the state of São Paulo, Brazil.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT02538276; https://www.clinicaltrials.gov/ct2/show/NCT02538276 (Archived by WebCite at http://www.webcitation.org/6m7APnFLD).
authors.affiliation: Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, Brazil.
authors.forename: Edwaldo Edner
authors.identifier: http://orcid.org/0000-0001-7237-4771
authors.initials: EE
authors.lastname: Joviliano
authors.affiliation: Department of Surgery, Botucatu Medical School, University Julio de Mesquita Filho UNESP, Botucatu, Brazil.
authors.forename: Winston Bonetti
authors.identifier: http://orcid.org/0000-0002-2921-3777
authors.initials: WB
authors.lastname: Yoshida
authors.affiliation: Department of Surgery, Botucatu Medical School, University Julio de Mesquita Filho UNESP, Botucatu, Brazil.
authors.forename: Marcone Lima
authors.identifier: http://orcid.org/0000-0003-2271-5878
authors.initials: ML
authors.lastname: Sobreira
authors.affiliation: Department of Surgery, Botucatu Medical School, University Julio de Mesquita Filho UNESP, Botucatu, Brazil.
authors.forename: Regina
authors.identifier: http://orcid.org/0000-0002-5002-5666
authors.initials: R
authors.lastname: Moura
authors.affiliation: Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil.
authors.forename: Ana Terezinha
authors.identifier: http://orcid.org/0000-0002-5487-4892
authors.initials: AT
authors.lastname: Guillaumon
authors.affiliation: Department of Surgery, São Jose do Rio Preto Medical School FAMERP, Sao Jose do Rio Preto, Brazil.
authors.forename: Selma Regina De Oliveira
authors.identifier: http://orcid.org/0000-0001-8705-7146
authors.initials: SR
authors.lastname: Raymundo
authors.affiliation: Department of Surgery, São Jose do Rio Preto Medical School FAMERP, Sao Jose do Rio Preto, Brazil.
authors.forename: Daniel Gustavo
authors.identifier: http://orcid.org/0000-0001-5734-1314
authors.initials: DG
authors.lastname: Miquelin
authors.affiliation: Department of Surgery, Marilia Medical School FAMEMA, Marilia, Brazil.
authors.forename: Ludvig
authors.identifier: http://orcid.org/0000-0002-6536-8768
authors.initials: L
authors.lastname: Hafner
authors.affiliation: Department of Surgery, Marilia Medical School FAMEMA, Marilia, Brazil.
authors.forename: Marcelo Jose
authors.identifier: http://orcid.org/0000-0002-9143-604X
authors.initials: MJ
authors.lastname: Almeida
keywords: carotid artery diseases; carotid endarterectomy; carotid stenosis; carotid stenting; medical record linkage