April 23, 2012
CEA and CAS Comparative Effectiveness Evaluated in Medicare Population
April 20, 2012—An evaluation of the comparative effectiveness of carotid revascularization procedures stratified by Medicare age was published March 30 online ahead of print in the Journal of Vascular Surgery by Jeffrey Jim, MD, et al for the Society for Vascular Surgery (SVS) Outcomes Committee.
Using data from the SVS Vascular Registry, this study reported the influence of age on the comparative effectiveness of carotid endarterectomy (CEA) and carotid artery stenting (CAS). CAS resulted in inferior 30-day outcomes in symptomatic and asymptomatic patients aged ≥ 65 years compared with CEA; therefore, these findings do not support the widespread use of CAS in patients aged ≥ 65 years, the investigators concluded.
According to the investigators, the Vascular Registry collects provider-reported data on patients using a Web-based database. Patients were stratified by age and symptoms. The primary endpoint was the composite outcome of death, stroke, or myocardial infarction (MI) at 30 days.
As reported in the Journal of Vascular Surgery, as of December 7, 2010, there were 1,347 CEA and 861 CAS patients aged < 65 years and 4,169 CEA and 2,536 CAS patients aged ≥ 65 years. CAS patients in both age groups were more likely to have a disease etiology of radiation or restenosis, be symptomatic, and have more cardiac comorbidities.
In patients aged < 65 years, the primary endpoint (5.23% CAS vs 3.56% CEA; P = .065) did not reach statistical significance. Subgroup analyses showed that CAS had a higher combined death/stroke/MI rate (4.44% vs 2.1%; P < .031) in asymptomatic patients but there was no difference in the symptomatic (6% vs 5.47%; P = .79) group.
In patients aged ≥ 65 years, CEA had lower rates of death (0.91% vs 1.97%; P < .01), stroke (2.52% vs 4.89%; P < .01), and composite death/stroke/MI (4.27% vs 7.14%; P < .01). CEA in patients aged ≥ 65 years was associated with lower rates of the primary endpoint in symptomatic (5.27% vs 9.52%; P < .01) and asymptomatic (3.31% vs 5.27%; P < .01) subgroups. After risk adjustment, the investigators stated that CAS patients aged ≥ 65 years were more likely to reach the primary endpoint.