Clinical Outcome of Carotid Artery Stenting According to Provider Specialty and Volume

Abstract

Background Several studies have demonstrated better outcomes for carotid endarterectomy with high-volume hospitals and providers. However, only a few studies have reported on the impact of operator specialty/volume on the perioperative outcome of carotid artery stenting (CAS). This study will analyze the correlation of CAS outcomes and provider specialty and volume. Methods Prospectively collected data of CAS procedures done at our institution during a 10-year period were analyzed. Major adverse events (MAEs; 30-day stroke, myocardial infarction, and death) were compared according to provider specialty (vascular surgeons [VSs], interventional cardiologists [ICs], interventional radiologists [IRs], interventional vascular medicine [IVM]), and volume (≥5 CAS/year vs. <5 CAS/year). Results Four hundred fourteen CAS procedures (44% for symptomatic indications) were analyzed. Demographics/clinical characteristics were somewhat similar between specialties. MAE rates were not significantly different between various specialties: 3.1% for IC, 6.3% for VS, 7.1% for IR, 6.7% for IVM (P = 0.3121; 6.3% for VS and 3.8% for others combined, P = 0.2469). When physicians with <5 CAS/year were excluded: the MAE rates were 3.1% for IC, 4.7% for VS, and 6.7% for IVM (P = 0.5633). When VS alone were compared with others, and physicians with <5 CAS/year were excluded, the MAE rates were 4.7% for VS vs. 3.6% for non-VS (P = 0.5958). The MAE rates for low-volume providers, regardless of their specialty, were 9.5% vs. 4% for high-volume providers (P = 0.1002). Logistic regression analysis showed that the odds ratio of MAE was 0.4 (0.15–1.1, P = 0.0674) for high-volume providers, while the odds ratio for VS was 1.3 (0.45–3.954, P = 0.5969). Conclusions Perioperative MAE rates for CAS were similar between various providers, regardless of specialties, particularly for vascular surgeons with similar volume to nonvascular surgeons. Low-volume providers had higher MAE rates.

Long-Term Outcomes of Carotid Endarterectomy and Carotid Artery Stenting When Performed by a Single Vascular Surgeon

“…Several prior studies have shown similar postoperative outcomes of CAS when performed by different specialities. [24][25][26][27][28] However, in a subgroup analysis of CREST, the periprocedural risk of stroke following CAS was higher when performed by vascular surgeons compared to interventional cardiologists and neuroradiologists. 29 We have previously reported short-term outcomes of CEA and CAS for high-grade carotid artery stenosis performed by a single vascular surgeon at our institution and showed similar outcomes between the 2 procedures that were also comparable to those of CREST.…”

“…28 Another study by AbuRahma et al on 30-day rates of MAEs after CAS performed by different specialties were 3.1% with interventional cardiology, 6.3% with vascular surgeons, 7.1% with interventional radiologists, and 6.7% with interventional vascular medicine. 24 However, in an analysis of the National Inpatient Sample NIS, Sgroi et al reported that the majority of CAS procedures in the country were performed by vascular surgeons and that postoperative unadjusted outcomes of stroke and MI were similar between the vascular surgeons and interventional specialties. 28 The authors concluded that the volume of cases performed by a provider, rather than the provider's specialty, seems a stronger predictor of adverse outcomes for CAS.…”

“…22,23 Subgroup analysis from CREST showed that most minor strokes occurred on the procedure day, while most major strokes, including hemorrhagic strokes, occurred several days after the procedure. 24 The timing of major stroke after revascularization suggests that a major stroke is potentially preventable. Moreover, the occurrence of minor strokes at the time of CAS suggests a potential for further improvement with expected advances in technology, technique, and training in CAS.…”

The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease

“…577 Vogel et al 587 588 However, the study showed that the interventionalists did have increased hospital charges and length of stay compared with the surgeons. Recently, AbuRahma et al 589 reported on the clinical outcome of CAS according to provider specialty and volume. Four hundred fourteen CAS procedures (44% for symptomatic indications) were analyzed.…”

Predictors of Perioperative Stroke/Death after Carotid Artery Stenting: A Review Article

“…AbuRahma et al 56 ) analyzed the correlation of CAS outcomes with operator’s specialty and volume. In their study, they analyzed prospectively collected data from 414 CAS procedures performed at their institution over a 10-year period.…”