Introduction: The CREST trial in 2010 showed higher complication rates with CAS than with CEA in elderly older than 70yo. Practice guidelines in 2011 have since recommended CEA for elderly patients if not contraindicated. However, the impact of CREST on contemporary trends of carotid revascularization in elderly is not well described.
Hypothesis: We hypothesize a temporal increase of CEA and decrease in CAS in elderly (age>70yo) hospitalized for symptomatic carotid stenosis after the publication of CREST in 2010.
Methods: Using data from the Nationwide Inpatient Sample, patients with symptomatic carotid stenosis admitted to hospitals from 2005 to 2014 with a discharge diagnosis of carotid artery stenosis with stroke or TIA were included. Primary analysis was the proportion of patients who received carotid revascularization (CEA or CAS) stratified by age (>70yo or ≤70yo) temporally. Survey-weighted logistic regression was used to estimate the rate for each year and compared across age.
Results: Of 59,866 patients admitted for symptomatic carotid stenosis, 26.0% had CEA and 5.2% had CAS with mean age of 69.9±0.1. In the 5 years before CREST, the rate of CEA decreased from 29.9% to 22.8%, with a subsequent increase up to 25.7% in the 4 years after CREST. The rate of CAS, however, increased precipitously from 3.5% to 6.8% from 2005-2014. The magnitude of increase in CEA after CREST trended higher in elderly compared to younger group (absolute increase 4.1% vs 1.6%), whereas the magnitude of the increase in CAS trended lower in elderly compared to younger group (2.7% vs 3.9%). Elderly admitted to urban/teaching hospitals had greater odds of getting CAS (OR 6.4, 95% CI 4.1-10.0, p<0.001).
Conclusions: The rate of CEA increased in elderly with symptomatic carotid stenosis in the United States since the publication of CREST in 2010. However, the hypothesized temporal decrease in CAS in elderly was not observed. Understanding more about decision making for CEA vs CAS in elderly is needed.