Interventionalists, Surgeons Achieve Similar CAS Outcomes, but Experience Counts
Surgeons appear to be performing most carotid artery stenting (CAS) procedures in the United States, and their patients typically spend less time in the hospital and have lower procedural costs compared with those treated by interventionalists, according to a registry study published online January 16, 2015, ahead of print in the Journal of Vascular Surgery. However, hospital volume seems to influence stroke outcomes more than operator specialty.
Researchers led by Roy M. Fujitani, MD, of the University of California, Irvine (Orange, CA), examined 20,663 inpatient CAS procedures documented in the Nationwide Inpatient Sample database from 2004 to 2011. Most cases (74%) were performed by surgeons—defined as physicians who also performed a carotid endarterectomy and either a femoral-popliteal bypass or arteriovenous fistula during the same calendar year—while the rest were done by interventionalists.
Baseline characteristics and demographics were similar between the operator groups, and the majority of cases were performed in urban hospitals and teaching institutions. Average patient age was about 71 years, and about 61% were male.
Shorter Hospital Stays With Surgeons
Outcomes remained stable overall throughout the 7-year study period; mortality occurred in < 1% of patients, stroke in 4% to 6%, and MI in 2%, “similar to the rates presented in the multiple randomized studies on the topic,” Dr. Fujitani and colleagues write.
Unadjusted stroke, MI, and mortality outcomes were similar irrespective of operator specialty, but patients treated by interventionalists tended to have longer hospital stays and higher total hospital costs (table 1).
Multivariate analysis confirmed the results, with differences in length of stay (P = .002) and cost (P = .003) still favoring procedures performed by surgeons.
Additionally, each 10-case increase in volume was associated with a lower risk of stroke across different centers (P = .021).
‘Substantial Experience’ A Necessity
Since CAS vs endarterectomy trials like SAPPHIRE, SPACE, and CREST, “there has been an exhaustive amount of literature debating the use of stenting compared with carotid endarterectomy, and during this time, a broad spectrum of physicians have been deploying stents,” the study authors write. “With so many different physicians performing this procedure, it begs the question, ‘Who has the best outcomes?’”
This study suggests that surgeons and interventionalists achieve similar outcomes and “affirms that the volume of cases performed at an institution is more important…,” Dr. Fujitani and colleagues write. “A concern arises, however, with the fact that most institutions do not perform many of these on a yearly basis. Therefore, if multiple different providers are all performing the same procedure, it is our belief that outcomes will be worse because instead of having 1 provider with substantial experience, multiple providers will all have inadequate experience.”
They note that the CAS vs surgery debate is no longer the emphasis as plenty of trials have confirmed similar safety and efficacy outcomes with both procedures. But “there appears to be an advantage to having a vascular surgeon perform the operation instead of an interventionalist,” they note, pointing to the differences in length of stay and hospital charges.
The authors hypothesize that the reasons for a longer hospital stay seen with interventionalists could be related to the fact that they typically do not care for inpatients. Rather, these patients are cared for by a hospitalist or other provider after their procedures. “This may lead not only to increased stay in the hospital but also to the possibility of incorrect postoperative care,” they say.
Differences in cost could be due partially do the lengthened hospital stay, Dr. Fujitani and colleagues write, but it is hard to know for sure because “similar instruments and equipment are used no matter who is performing the intervention.”
Sgroi MD, Darby GC, Kabutey N-K, et al. Experience matters more than specialty for carotid stenting outcomes. J Vasc Surg. 2015;Epub ahead of print.
- Dr. Fujitani reports no relevant conflicts of interest.