National patterns of carotid revascularization before and after The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST)

Abstract

Importance: The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) showed greater safety of carotid artery stenting (CAS) in patients younger than 70 years and carotid endarterectomy (CEA) in those older than 70 years. It is unknown how the result of CREST has influenced carotid revascularization choices in the United States. Objective: To evaluate national patterns in CAS performance in patients older than 70 years in the post-CREST (2011-2014) compared with the pre-CREST (2007-2010) era. Design, Setting, and Participants: All adults older than 70 years undergoing carotid revascularization in the United States from 2007 to 2014 were retrospectively identified from the 2007-2014 National Inpatient Sample using International Classification of Disease, Ninth Revision procedural codes. From 61 324 882 unweighted hospitalizations contained in the 2007-2014 National Inpatient Sample, 494 733 weighted carotid revascularization admissions in adults older than 70 years were identified using International Classification of Disease, Ninth Revision procedural codes. Main Outcomes and Measures: The proportion of CAS performed in all age groups over time was estimated and multivariable-adjusted models were used to compare the odds of receiving CAS in the pre-CREST with those in the post-CREST era in adults older than 70 years. Results: A total of 41.8%of all patients were women, and mean (SE) age at presentation was 78.1 (0.03) years. A total of 16.3%of CAS and 10.1%of CEA procedures were performed in patients with symptomatic stenosis. The proportion of patients older than 70 years receiving CAS increased from 11.9%in the pre-CREST to 13.8% in the post-CREST era (P = .005). In multivariable models, the odds of receiving CAS increased by 13%in all patients older than 70 years in the post-CREST compared with the pre-CREST period (odds ratio [OR], 1.13, 95%CI, 1.00-1.28, P = .04), including symptomatic women (OR, 1.31, 1.05-1.65, P = .02). Symptomatic stenosis (OR 1.39; 95%CI, 1.27-1.52; P < .001), congestive heart failure (OR, 1.48; 95%CI, 1.35-1.63; P < .001), and peripheral vascular disease (OR, 1.35; 95%CI, 1.27-1.43; P < .001) were associated with higher odds of CAS; comorbid hypertension (OR, 0.70; 95%CI, 0.66-0.74; P < .001), smoking (OR, 0.84; 95%CI, 0.78-0.91; P < .001), and weekend admission (OR, 0.77; 95%CI, 0.68-0.88; P < .001) were negatively associated with the odds of CAS. Conclusions and Relevance: Despite concerns for higher periprocedural complications with CAS in elderly patients, the odds of CAS increased in the post-CREST compared with pre-CREST era in patients older than 70 years, including symptomatic women.