Clinical Referral Patterns for Carotid Artery Stenting Versus Carotid Endarterectomy
Open Access
- 1 February 2011
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Circulation: Cardiovascular Interventions
- Vol. 4 (1), 88-94
- https://doi.org/10.1161/circinterventions.110.958843
Abstract
Background— Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. Although randomized clinical trials are the gold standard for assessing the relative benefits of different treatments, observational research is necessary for determining “real-world” effectiveness. Current recommendations limit the application of CAS to high-risk patients, undermining the ability to “balance” the characteristics of patients treated with either approach. We compared the clinical profiles of patients referred for CAS versus CEA in a large national database. Methods and Results— Clinical characteristics of 12 701 patients referred for CAS or CEA in the National Cardiovascular Data Registry–Carotid Artery Revascularization and Endarterectomy were compared for 44 clinical and demographic variables. To investigate the comparability of CAS and CEA patients, we stratified the cohort into quintiles of the propensity score for referral for CAS. Among 8069 patients referred for CAS and 4632 referred for CEA, the CAS patients had significantly more comorbidities. Whereas the propensity model balanced most covariates, the pooled standardized differences (≥10%) suggested persistent imbalance for ischemic heart disease, recent myocardial infarction, and restenosis of prior CAS/CEA, all of which were more common in the CAS group. After stratification of propensity scores by quintile, CEA patients comprised only 14% of the upper 2 quintiles. Conclusions— Characteristics of patients referred for CAS differ markedly from those referred for CEA. Because of extreme clinical disparities between these patients, generalizable comparative effectiveness analyses of observational data will be difficult.Keywords
This publication has 21 references indexed in Scilit:
- Therapeutic MilestoneStroke, 2010
- Clinical features and outcomes of carotid artery stenting by clinical expert consensus criteria: A report from the CARE registryCatheterization and Cardiovascular Interventions, 2009
- The Relative Ability of Different Propensity Score Methods to Balance Measured Covariates Between Treated and Untreated Subjects in Observational StudiesMedical Decision Making, 2009
- Dealing with limited overlap in estimation of average treatment effectsBiometrika, 2009
- Predictors of Death and Stroke After Carotid Angioplasty and StentingStroke, 2008
- The carotid artery revascularization and endarterectomy (CARE) registry: Objectives, design, and implicationsCatheterization and Cardiovascular Interventions, 2008
- 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trialThe Lancet, 2006
- Risk and Predictors of Stroke After Myocardial Infarction Among the ElderlyCirculation, 2002
- Carotid Recurrent Stenosis and Risk of Ipsilateral StrokeStroke, 1998
- The central role of the propensity score in observational studies for causal effectsBiometrika, 1983