National Patterns of Carotid Revascularization Before and After the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST)

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CREST demonstrated subtle advantage of carotid endarterectomy (CEA) compared to carotid artery stenting (CAS) in subgroup analysis. Specifically, patients receiving CEA had lower rates of stroke despite no difference in composite outcomes which included myocardial ischemia. In the present study, the Nationwide Inpatient Sample database from 2007-2014 was queried for patients receiving either CAS or CEA using their respective ICD-9 codes. Demographic, social, and clinical characteristics were examined for correlation to receiving CAS vs CEA. Cohorts were divided into pre-CREST era (2007-2010) and post-CREST era (2011-2014). The number of revascularization procedures per million hospitalizations for patients age 70 and above decreased over this time period, but contrary to expectations based on CREST data, the proportion of CAS increased from 11.9% to 13.8% (P=0.005).  Proportion of symptomatic patients receiving a procedure rose from 9.0% in 2007 to 13.9% in 2014, with an increase in the odds of receiving CAS by 40%. Symptomatic women were 30% more likely to receive CAS following CREST. 

Stephen Grupke, MD
Lexington, KY