Carotid endarterectomy versus stenting, 1999-2014

Lichtman et al in their article published in JAMA address the issue of carotid endarterectomy and stenting outcomes in the U.S. in the years 1999 to 2014.

In their study that included Medicare beneficiaries, the national annualized rate of carotid endarterectomy per 100 000 beneficiary-years decreased from 298 in 1999-2000 to 128 in 2013-2014, whereas the rate of carotid artery stenting initially 40 in 1999-2000 increased to 75 in 2005-2006 followed by a decline to 38 in 2013-2014.

During the study, 937 111 unique patients underwent carotid endarterectomy (mean age, 75.8 years) and 231 077 underwent carotid artery stenting (mean age, 75.4 years).

Outcomes improved over time despite increases in vascular risk factors such as hypertension prevalence that increased from 67% to 81% among patients who underwent endarterectomy and from 61% to 70% among patients who underwent stenting.  The adjusted annual decreases in 30-day ischemic stroke or death of 2.90% among patients who underwent endarterectomy and 1.13% among patients who underwent stenting.  The 1-year ischemic stroke decreased to 3.5% after endarterectomy and 1.6% after stenting. Additional improvements were noted for in-hospital mortality, 30-day stroke, myocardial infarction, or death, and 30-day all-cause mortality.

Carotid endarterectomies declined from 1999 to 2014, whereas carotid artery stenting increased until 2006 and then declined from 2007 to 2014. Outcomes improved despite increases in vascular risk factors.