Caitlin W Hicks1, Besma Nejim1, Satinderjit Locham1, Hanaa D Aridi1, Marc L Schermerhorn2, Mahmoud B Malas3. 1. Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md. 2. Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. 3. Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Md. Electronic address: bmalas1@jhmi.edu.
Abstract
BACKGROUND: The U.S. Centers for Medicare and Medicaid Services (CMS) has defined a set of high-risk criteria to help define patients who are appropriate for carotid artery stenting (CAS), but these criteria have never been validated. We aimed to validate the CMS high-risk criteria in a nationally representative cohort of patients undergoing CAS and carotid endarterectomy (CEA). METHODS: All patients undergoing CAS (with embolic protection) or CEA in the Vascular Quality Initiative (VQI) database (2013-2016) were included. Patients were stratified as being at normal risk (Nr) or high risk (Hr) for undergoing CEA on the basis of CMS criteria. Thirty-day and 2-year stroke outcomes were compared for CAS vs CEA in both the Nr and Hr groups using 1:1 coarsened exact matching and multivariable Cox proportional hazards modeling. RESULTS: A total of 51,942 patients (CAS, 7030; CEA, 44,912) underwent carotid revascularization during the study period. Thirty-day (Nr, 1.7% vs 1.0%; Hr, 2.5% vs 1.4%) and 2-year (Nr, 1.9% vs 1.0%; Hr, 2.4% vs 1.3%) stroke occurred more frequently after CAS vs CEA on crude analysis (P < .001). After matching 2920 pairs of patients on 18 preoperative variables, the risk of 30-day and 2-year stroke remained higher after CAS in the Hr group (30-day risk: hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.26-2.85; 2-year risk: HR, 1.65; 95% CI, 1.05-2.60) but was similar for CAS vs CEA in the Nr group (30-day risk: HR, 0.97; 95% CI, 0.48-1.95; 2-year risk: HR, 1.49; 95% CI, 0.76-2.90). CONCLUSIONS: These data suggest that the utility of CAS in Nr patients may be underappreciated, whereas the potential benefit of CAS in Hr patients may be overestimated. Re-evaluation of the criteria for identifying patients at high risk for CEA and the national guidelines on the indications for CAS is strongly indicated.
BACKGROUND: The U.S. Centers for Medicare and Medicaid Services (CMS) has defined a set of high-risk criteria to help define patients who are appropriate for carotid artery stenting (CAS), but these criteria have never been validated. We aimed to validate the CMS high-risk criteria in a nationally representative cohort of patients undergoing CAS and carotid endarterectomy (CEA). METHODS: All patients undergoing CAS (with embolic protection) or CEA in the Vascular Quality Initiative (VQI) database (2013-2016) were included. Patients were stratified as being at normal risk (Nr) or high risk (Hr) for undergoing CEA on the basis of CMS criteria. Thirty-day and 2-year stroke outcomes were compared for CAS vs CEA in both the Nr and Hr groups using 1:1 coarsened exact matching and multivariable Cox proportional hazards modeling. RESULTS: A total of 51,942 patients (CAS, 7030; CEA, 44,912) underwent carotid revascularization during the study period. Thirty-day (Nr, 1.7% vs 1.0%; Hr, 2.5% vs 1.4%) and 2-year (Nr, 1.9% vs 1.0%; Hr, 2.4% vs 1.3%) stroke occurred more frequently after CAS vs CEA on crude analysis (P < .001). After matching 2920 pairs of patients on 18 preoperative variables, the risk of 30-day and 2-year stroke remained higher after CAS in the Hr group (30-day risk: hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.26-2.85; 2-year risk: HR, 1.65; 95% CI, 1.05-2.60) but was similar for CAS vs CEA in the Nr group (30-day risk: HR, 0.97; 95% CI, 0.48-1.95; 2-year risk: HR, 1.49; 95% CI, 0.76-2.90). CONCLUSIONS: These data suggest that the utility of CAS in Nr patients may be underappreciated, whereas the potential benefit of CAS in Hr patients may be overestimated. Re-evaluation of the criteria for identifying patients at high risk for CEA and the national guidelines on the indications for CAS is strongly indicated.
Authors: Marc L Schermerhorn; Patric Liang; Hanaa Dakour-Aridi; Vikram S Kashyap; Grace J Wang; Brian W Nolan; Jack L Cronenwett; Jens Eldrup-Jorgensen; Mahmoud B Malas Journal: J Vasc Surg Date: 2019-06-18 Impact factor: 4.268
Authors: Michiel H F Poorthuis; Reinier A R Herings; Kirsten Dansey; Johanna A A Damen; Jacoba P Greving; Marc L Schermerhorn; Gert J de Borst Journal: Stroke Date: 2021-10-12 Impact factor: 7.914
Authors: Pavel Kibrik; David P Stonko; Ahmad Alsheekh; Courtenay Holscher; Devin Zarkowsky; Christopher J Abularrage; Caitlin W Hicks Journal: J Vasc Surg Date: 2022-05-25 Impact factor: 4.860
Authors: George Q Zhang; Sanuja Bose; David P Stonko; Christopher J Abularrage; Devin S Zarkowsky; Caitlin W Hicks Journal: J Vasc Surg Date: 2022-03-31 Impact factor: 4.860