1. In this analysis of treatment patterns in the United States for the years prior to, and following, the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST), the use of carotid artery stenting (CAS) rose amongst patients 70 years and older despite the evidence for worse outcomes.
2. The increase in utilization of CAS also rose in women, who were shown to have increased risk of periprocedural complications with CAS in the CREST study.
Evidence Rating Level: 3 (Average)
Study Rundown: The CREST study published in 2010 compared the use of CAS with carotid endarterectomy (CEA) in patients with severe carotid artery stenosis and demonstrated no differences in primary endpoint between the two strategies. However, in subgroup analysis age and sex were found to be important factors in outcome. Patients older than 70 years had better outcome with CEA, while younger patients fared better with CAS. Risk of periprocedural complications was higher for women undergoing CAS than with men. How the results of CREST influenced practice patterns is not certain. The current study evaluated the use of CAS amongst adults older than 70 years in the United States during the 3 years before and after the CREST study. The investigation found that despite the results of the CREST study the use of CAS increased amongst older patients, including women.
The current study highlights continued practice patterns despite evidence from ongoing clinical trials. The main confounders would include the variable interpretations of the results of the CREST trial, as it compares to the favorability of CAS in other studies. Developments of newer stenting technologies may also influence treatment decisions. The main limitations of the study include the retrospective design, and reliance on diagnostic codes and the lack of data on important factors that may influence treatment decisions such as important patient comorbidities.
In-Depth [retrospective cohort]: This study included data from Nationwide Inpatient Sample (NIS) database, using data from 2007-2010 (pre-CREST) and 2011-2014 (post-CREST) which is a 20% random sample of all discharges in the United States. Patients were included if they were 70 years or older, and were undergoing carotid revascularization, identified using International Classification of Diseases, Ninth Revision (ICD-9) procedural codes.
During the study period there were 494 733 carotid revascularization procedures performed on adults 70 years or older. Of these patients 87.2% underwent CEA and 12.8% underwent CAS. The proportion of patients undergoing CAS during the pre-CREST period was 11.9%, while it was 13.8% in the post-CREST period (p = 0.005). The odds of receiving CREST increased by 13% during this period (odds ratio [OR], 1.13, 95%CI, 1.00-1.28, p = 0.04). This increase in odds of CAS was also observed amongst women (OR, 1.31, 1.05-1.65, p = 0.02).
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