Study Compares CAS Outcomes by Specialty


June 3, 2009—In the Journal of Vascular Surgery, Robert Steppacher, MD, et al have published findings from an analysis of carotid artery stenting (CAS) procedures performed in New York and Florida from 2005 to 2006 that compared procedure indications, stroke rates, and mortality rates for vascular surgeons and nonvascular surgeons (2009;49:1379–1385).

The investigators found that perioperative rates of stroke and death are equivalent among vascular surgeons, interventional cardiologists, and interventional radiologists. Also, regional variation of operator type is substantial, and despite similar outcomes, < 50% of CAS procedures are performed by vascular surgeons, the investigators concluded.

The background for the study was that with the emergence of CAS as an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis, a variety of specialists are performing the procedure. This study compares the indications, in-patient mortality rate, and in-patient stroke rate for patients undergoing CAS according to operator specialty.

According to the investigators, the in-patient databases from New York and Florida, made available by the Healthcare Cost and Utilization Project, were reviewed by International Classification of Disease 9-CM codes to identify all patients treated with CAS for the years 2005 and 2006. This cohort was then stratified according to operator specialty defined by procedures performed by each operator over the years surveyed. Primary endpoints were in-patient death and stroke. Propensity score matching adjusting for indication, demographics, and comorbidities was used to evaluate the influence of operator type on outcomes.

The investigators reported that during the study period, 4,001 CAS procedures were performed. All primary analyses compared vascular surgeons (n = 1350) to nonvascular surgeons (n = 2651). Patient characteristics were similar, except vascular surgeons treated fewer patients with coronary artery disease (44.2% vs 50.9%; P < .001) and valvular disease (6.3% vs 8.6%; P = .01) and more patients with chronic lung disease (19.4% vs 15.9%; P = .01). Each group performed an equal proportion of CAS for symptomatic disease (8.1% vs 9%; P = .32). Univariate analysis revealed no difference in mortality (0.9% vs 0.5%; P = .13) or stroke (1.3% vs 1.5%; P = .73) rates. Propensity score matched analysis also demonstrated no difference in mortality (0.7% vs 0.4%; P = .48) or stroke (1.1% vs 1.7%; P = .27).

Subgroup analysis comparing vascular surgeons, interventional cardiologists, and interventional radiologists showed no significant difference in mortality or stroke but demonstrated that of the three specialties, interventional cardiologists treated the smallest proportion of symptomatic patients. The proportion of CAS performed by vascular surgeons differed significantly by state (New York 46%, Florida 19%; P < .01), the investigators stated in the Journal of Vascular Surgery.

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