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Background: In 2005, the Center for Medicare Services (CMS) approved the reimbursement for carotid artery stenting for high-risk carotid stenosis; leaving carotid endarterectomy (CEA) to be performed primarily for a low-risk population. In this study, we assess trends of outcomes associated with CEA over the period of CMS regulation.Methods: A cohort of patients with CEA was identified from the National Inpatient Sample database using the procedure codes (38.12) for the years 2001 through 2009. Patients under age 18, missing information on the death status, transfer between hospitals, and urgent or emergent admissions were eliminated. Trend analysis for the following outcomes (post procedure stroke, myocardial infarction ‘MI’, and death) was performed over the year included in the study. Two periods encompass the implementation of the guideline (first period: 2001 through 2004 and second period: 2006 through 2009) were compared.Results: Over 9 years, 152 051 CEA procedures were performed; 63375 performed during the first period and 70886 in the second period. The mean age (71.02 ± 9.2) and male preponderance (57.4%) were similar in both treatment periods (P > 0.05). Ninety six percent of this population was asymptomatic by the time CEA was performed. Overall poor outcome risk of post-procedure stroke, MI and death was 1.97%; being lower in the second compared to the first period (2.05% versus 1.88%; P =0.02; unadjusted odds ratio “OR’ 0.91; 95% CI, 0.84, 0.98; and adjusted OR 0.88; 95% CI, 0.82, 0.96). The risk of post-procedure stroke was similar in both periods (0.94% versus 0.97%; P = 0.56); however, the risks of MI (0.91% versus 0.76%; P = 0.002) and death (0.46% versus 0.33%; P < 0.0001) declined over time.Conclusion: Following the CMS reimbursement guideline, CEA is associated with lesser risks of poor outcomes (MI and death).