Background: The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) showed greater safety of carotid artery stenting (CAS) in patients (pts) <70 yo and endarterectomy (CEA) in >70 yo. The aim of this study was to evaluate national patterns in CAS performance in pts >70yo in the pre- (2007-2010) and post-CREST (2011-2013) era.
Methods: Adults requiring CAS or CEA were identified from the 2007-2013 Nationwide Inpatient Sample (NIS) using International Classification of Disease (ICD-9) codes. We estimated the proportion of CAS performed in all age groups and used multivariate models adjusted for clinical and hospital factors to compare odds of receiving CAS in the pre- to post-CREST era.
Results: We identified 839,357 weighted cases of CAS and CEA from the NIS. 15.7% of CAS and 8.4% of CEA were performed in symptomatic pts. CAS increased in all age groups over time (figure 1). Proportion of >70yo receiving CAS increased from 11.9% in the pre- to 13.9% in the post-CREST era (p=0.004). In multivariate models, odds of receiving CAS as opposed to CEA increased by 15% in all pts >70yo in the post-CREST compared to the pre-CREST period (OR 1.15, 95%CI 1.10-1.19, p<0.001) including asymptomatic women (OR 1.10, 1.03-1.18). Congestive heart failure (OR 1.50, 95%CI 1.41-1.60), peripheral vascular disease (OR 1.41, 95%CI 1.34-1.48) and hospitalization in the Western region as opposed to the Northeast (OR 1.25, 95%CI 1.16-1.34) were associated with higher odds of CAS in pts>70yo, while female sex (OR 0.92, 95%CI =0.89-0.97), smoking (OR 0.84, 95%CI 0.79-0.90) and weekend admission (OR 0.78, 95%CI 0.70-0.86) were negatively associated with odds of CAS.
Conclusion: Rates of CAS increased in the post- compared to pre-CREST era in pts >70yo including asymptomatic women. Despite the concerns of higher periprocedural complications with CAS in elderly pts, the results of CREST have not influenced clinical revascularization practice in pts >70yo.