December 12, 2008

Is CAS Being Performed Preferentially in High Risk Surgical Patients?

Jason T. Lee, MD, Tom C. Nguyen, MD, Mediget Teshome, MD, Mary Qiu, BS, Shyam Raghavan, BS, Ronald L. Dalman, MD, John Morton, MD.
Stanford University Medical Center, Stanford, CA, USA.

OBJECTIVES:
While carotid angioplasty/stenting (CAS) is offered as the preferred alternative to carotid endarterectomy (CEA) for high risk patients, the national utilization of CAS in its intended population cohort remains unknown. Using the Charlson Index as a surrogate for patient risk, we hypothesized CAS would be increasingly performed over time on a nationwide basis in higher risk patients.
METHODS:
Hospital discharge data from the Nationwide Inpatient Sample was queried from 2002 to 2005 for all patients undergoing CEA (38.12) and CAS (00.63; 39.50; 39.90). The Charlson Index containing 19 comorbidities was used to stratify patients according to low (Charlson 0-1) and high (Charlson 2-3) risk. Primary outcome measures were stroke, myocardial infarction, wound-related complications, length of stay (LOS), total charges, and death.
RESULTS:
CAS utilization increased by 30% while CEA utilization declined by 19% during the study period. More CAS procedures were performed at teaching hospitals than CEA (57 vs. 39%), with total charges for CAS greater than CEA ($41,224 vs. 26,737). Mortality was higher each year for CAS when compared to CEA (Figure A). Initially, the CAS group had a higher proportion of high risk patients than CEA in 2002 (21 vs. 16% respectively). Over time, however, the percentage of high risk CAS patients declined compared to those offered CEA (Figure B).
CONCLUSIONS:
From 2002 to 2005, CAS has increased in utilization with a concomitant decline in CEA. The percentage of high risk patients undergoing CAS has been declining, while the percentage of high risk patients undergoing CEA was on the rise. Using the Charlson Index as a surrogate for surgical risk, despite published guidelines to the contrary, current practice patterns do not confirm that CAS is being offered preferentially to patients identified as high risk for traditional CEA.

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