Object: There is no known standard 30-day morbidity and mortality rate for high-risk patients undergoing carotid artery (CA) angioplasty and stent (CAS) placement. The high-risk registries and the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy, Carotid Revascularization using Endarterectomy or Stenting Systems, and European Long-term Carotid Artery Stenting trials report different rates of morbidity and mortality, and each high-risk cohort has a different risk profile. The applicability of carotid endarterectomy (CEA) results from North American Symptomatic Carotid Endarterectomy Trial/Asymptomatic Carotid Atherosclerosis Study (NASCET/ACAS) remains uncertain, as most clinical CAS placement series reported to date typically included patients who would not have qualified for those studies. At the University at Buffalo, the same neurosurgeons perform triage in patients with CA disease and perform both CEA and CAS insertion. The authors review morbidity and mortality rates in this practice model.
Methods: Diagnosis-related group codes were used to search the authors' practice database for patients who had undergone a completed CA intervention solely for the indication of atherosclerotic disease. One hundred twenty patients (129 vessels) treated with CAS surgery and 95 patients (100 vessels) treated with CEA met these criteria. In the CAS placement group, 78% of the patients would not have met NASCET/ACAS inclusion criteria. Demographic and clinical data for both groups were recorded on a spreadsheet for analysis. At 30 days, one patient in the CEA group and two in the CAS group had died. Stroke occurred in one patient in the CAS group and none in the CEA group. Myocardial infarction (MI) occurred in one patient who underwent CAS surgery compared with three undergoing CEA. Composite incidence of stroke/death/MI was 3.3% in the CAS group and 3.2% in the CEA group.
Conclusions: In a practice in which surgeons perform both CEA and CAS surgery, the event rates for the CAS surgery equivalent to NASCET and ACAS rates for CEA can be achieved, even in high-risk NASCET/ACAS-ineligible patients in 78% of the CAS cases.