In the Journals

Carotid stenting increasing among elderly population in recent years

The odds of undergoing carotid artery stenting, compared with carotid endarterectomy, increased significantly from 2007-2010 to 2011-2014.

In a new study published in JAMA Neurology, Fadar Oliver Otite, MD, ScM, from the department of neurology at University of Miami Miller School of Medicine, and colleagues noted that the previously published CREST trial demonstrated better outcomes with carotid endarterectomy (CEA) vs. carotid artery stenting (CAS) in older patients, but data were lacking on how these results have affected clinical practice.

Trends over time

To gain insight into national trends, the researchers evaluated data from the Nationwide Inpatient Sample (NIS) on patients aged older than 70 years who underwent carotid revascularization from 2007 to 2014. The researchers identified 494,733 weighted carotid revascularization admissions in this age group using ICD-9 procedural codes.

Of the patients included in the study, 87.2% underwent CEA and 12.8% underwent CAS. Results indicated an increase from 9% in 2007 to 13.9% in 2014 in revascularization procedures performed in symptomatic patients (P < .001), with 16.3% of CAS and 10.1% of CEA procedures being performed for symptomatic stenosis.

From the pre-CREST era (2007 to 2010) to the post-CREST era (2011-2014), the proportion of patients undergoing CAS increased from 11.9% to 13.8% (P = .005). After multivariable adjustment, the odds of undergoing CAS vs. CEA in elderly patients also increased from the pre-CREST to post-CREST time periods (OR = 1.13; 95% CI, 1-1.28). Additionally, the researchers observed an even greater increase in the odds of undergoing CAS in the subset of women with symptomatic stenosis (OR = 1.31; 95% CI, 1.05-1.65).

Results also showed that patients were more likely to undergo CAS if they had symptomatic stenosis (OR = 1.39; 95% CI, 1.2701.52), congestive HF (OR = 1.48; 95% CI, 1.35-1.63) and peripheral vascular disease (OR = 1.35; 95% CI, 1.27-1.43). However, patients were less likely to undergo CAS if they had comorbid hypertension (OR = 0.7; 95% CI, 0.66-0.74), were smokers (OR = 0.84; 95% CI, 0.78-0.91) and were admitted to the hospital during the weekend (OR = 0.77; 95% CI, 0.68-0.88).

“These findings are inconsistent with the results of CREST and suggest possible slow and incomplete incorporation of the trial results into clinical practice owing to interplay of a variety of factors,” the researchers wrote.

Cautious interpretation

There are a number of ways to interpret these findings, according to James F. Meschia, MD, from the department of neurology at Mayo Clinic in Jacksonville, Florida.

“Certain trends in the NIS seem counterintuitive,” he wrote in an accompanying editorial. “It is possible that the unexpected apparent enthusiasm for stenting in individuals older than 70 years relates to a perception among stent operators of a lower risk of periprocedural stroke with an evolving technology.”

He also highlighted the finding of a nonsignificant decline in CAS in both patients aged older and younger than 70 years from 2012 to 2014, which followed a steady increase from 2010 to 2012. CREST is having an effect on practice. However, it may be too early to draw firm conclusions, according to Meschia.

“Full translation of trial results into practice may take years, particularly when operators need to be persuaded rather than regulated into changing behavior,” Meschia wrote.

Furthermore, not all patients in this study would have been eligible for CREST, which further complicates interpretation of these findings.

“The study by Otite and colleagues reminds us of the importance of observational studies of trends in procedural practice. Nationally, carotid artery stenting continues to be perceived as an important option for stroke prevention. The next generation of trials of stenting in asymptomatic patients has the greatest potential to change practice,” Meschia wrote. – by Melissa Foster

Disclosures: One author reports he serves on the executive committee of the Carotid Revascularization Endarterectomy vs. Stenting Trial 2 and Asymptomatic Carotid Trial 1 studies. All other authors report no relevant financial disclosures. Meschia reports he receives funding from the National Institute of Neurological Disorders and Stroke to perform his duties as co-principal investigator for the CREST-2 Clinical Coordinating Center.

The odds of undergoing carotid artery stenting, compared with carotid endarterectomy, increased significantly from 2007-2010 to 2011-2014.

In a new study published in JAMA Neurology, Fadar Oliver Otite, MD, ScM, from the department of neurology at University of Miami Miller School of Medicine, and colleagues noted that the previously published CREST trial demonstrated better outcomes with carotid endarterectomy (CEA) vs. carotid artery stenting (CAS) in older patients, but data were lacking on how these results have affected clinical practice.

Trends over time

To gain insight into national trends, the researchers evaluated data from the Nationwide Inpatient Sample (NIS) on patients aged older than 70 years who underwent carotid revascularization from 2007 to 2014. The researchers identified 494,733 weighted carotid revascularization admissions in this age group using ICD-9 procedural codes.

Of the patients included in the study, 87.2% underwent CEA and 12.8% underwent CAS. Results indicated an increase from 9% in 2007 to 13.9% in 2014 in revascularization procedures performed in symptomatic patients (P < .001), with 16.3% of CAS and 10.1% of CEA procedures being performed for symptomatic stenosis.

From the pre-CREST era (2007 to 2010) to the post-CREST era (2011-2014), the proportion of patients undergoing CAS increased from 11.9% to 13.8% (P = .005). After multivariable adjustment, the odds of undergoing CAS vs. CEA in elderly patients also increased from the pre-CREST to post-CREST time periods (OR = 1.13; 95% CI, 1-1.28). Additionally, the researchers observed an even greater increase in the odds of undergoing CAS in the subset of women with symptomatic stenosis (OR = 1.31; 95% CI, 1.05-1.65).

Results also showed that patients were more likely to undergo CAS if they had symptomatic stenosis (OR = 1.39; 95% CI, 1.2701.52), congestive HF (OR = 1.48; 95% CI, 1.35-1.63) and peripheral vascular disease (OR = 1.35; 95% CI, 1.27-1.43). However, patients were less likely to undergo CAS if they had comorbid hypertension (OR = 0.7; 95% CI, 0.66-0.74), were smokers (OR = 0.84; 95% CI, 0.78-0.91) and were admitted to the hospital during the weekend (OR = 0.77; 95% CI, 0.68-0.88).

“These findings are inconsistent with the results of CREST and suggest possible slow and incomplete incorporation of the trial results into clinical practice owing to interplay of a variety of factors,” the researchers wrote.

Cautious interpretation

There are a number of ways to interpret these findings, according to James F. Meschia, MD, from the department of neurology at Mayo Clinic in Jacksonville, Florida.

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“Certain trends in the NIS seem counterintuitive,” he wrote in an accompanying editorial. “It is possible that the unexpected apparent enthusiasm for stenting in individuals older than 70 years relates to a perception among stent operators of a lower risk of periprocedural stroke with an evolving technology.”

He also highlighted the finding of a nonsignificant decline in CAS in both patients aged older and younger than 70 years from 2012 to 2014, which followed a steady increase from 2010 to 2012. CREST is having an effect on practice. However, it may be too early to draw firm conclusions, according to Meschia.

“Full translation of trial results into practice may take years, particularly when operators need to be persuaded rather than regulated into changing behavior,” Meschia wrote.

Furthermore, not all patients in this study would have been eligible for CREST, which further complicates interpretation of these findings.

“The study by Otite and colleagues reminds us of the importance of observational studies of trends in procedural practice. Nationally, carotid artery stenting continues to be perceived as an important option for stroke prevention. The next generation of trials of stenting in asymptomatic patients has the greatest potential to change practice,” Meschia wrote. – by Melissa Foster

Disclosures: One author reports he serves on the executive committee of the Carotid Revascularization Endarterectomy vs. Stenting Trial 2 and Asymptomatic Carotid Trial 1 studies. All other authors report no relevant financial disclosures. Meschia reports he receives funding from the National Institute of Neurological Disorders and Stroke to perform his duties as co-principal investigator for the CREST-2 Clinical Coordinating Center.