Intracranial Hemorrhage Is Much More Common After Carotid Stenting Than After Endarterectomy

Abstract

Background and Purpose-Intracranial hemorrhage (ICH) is a rare and devastating complication of carotid revascularization. We sought to determine the prevalence of, type of, and risk factors associated with ICH among recipients of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) within the National Inpatient Sample (NIS). Methods-Postoperative cases of ICH after CEA (International Classification of Disease 9 th edition [ICD-9]: 38.12) or CAS (ICD-9: 00.63) were retrieved from the 2001 to 2008 NIS. Clinical presentation (asymptomatic versus symptomatic), discharge status, in-hospital mortality, demographics, and hospital characteristics were extracted from NIS data. Charlson indices of comorbidity were determined based on ICD-9 and clinical classification software codes. Multivariate regression was used to determine the impact of revascularization procedure type and symptom status on adverse outcomes, including ICH, in-hospital mortality, and unfavorable discharge status. Results-Among 57 663 486 NIS hospital admissions, 215 012 CEA and 13 884 CAS procedures were performed.Symptomatic presentations represented the minority of CEA (Nϭ10 049; 5%) and CAS cases (Nϭ1251; 10%). ICH occurred significantly more frequently after CAS than CEA in both symptomatic (4.4% versus 0.8%; PϽ0.0001) and asymptomatic presentations (0.5% versus 0.06%; PϽ0.0001). Multivariate regression suggested that symptomatic presentations (versus asymptomatic) and CAS procedures (versus CEA) were both independently predictive of 6-fold to 7-fold increases in the frequency of postoperative ICH. ICH was independently predictive in a 30-fold increased risk of mortality before discharge. Conclusions-CAS procedures are associated with elevated adverse outcomes, including ICH, in-hospital death, and unfavorable discharges, especially among symptomatic presentations. (Stroke. 2011;42:2782-2787.)

Comparative Effectiveness of Carotid Revascularization Therapies

“…7 Finally, unlike CREST where the greater frequency of AMI in the CEA group offset the greater frequency of stroke in the CAS group, leading to equipoise in their composite clinical end point, our study found that rates of AMI rates were similar between CEA and CAS populations. Accordingly, exclusion of AMI in the modified composite outcome in our study failed to restore this equipoise, showing persistent clinical inferiority of CAS to CEA in the perioperative period with respect to these clinical outcomes.…”

“…The current findings expand on our prior efforts using the retrospective Nationwide Inpatient Sample in several key areas. 7 First, the Premier database has several advantages over the Nationwide Inpatient Sample as it is structured to distinguish between new medical diagnoses from preexisting conditions, includes medication data for each patient, and permits more accurate identification of procedures performed during the recorded hospitalization through inclusion of billing record data. Second, the use of propensity score matching on the same demographic and clinical inclusion variables used in prior prospective carotid revascularization studies simulates the randomization of these studies, markedly reducing confounding bias.…”

“…The current findings expand on our prior efforts using the retrospective Nationwide Inpatient Sample in several key areas. 7 First, the Premier database has several advantages over the same demographic and clinical inclusion variables used in prior prospective carotid revascularization studies simulates the randomization of these studies, markedly reducing confounding bias. Third, we incorporated numerous hospital variables in the matching model to minimize bias from geographic differences in clinical practice, stroke incidence, and operator experience.…”

“…7 Finally, unlike CREST where the greater frequency of AMI in the CEA group offset the greater freprospective studies. These prospective studies enforced varying degrees of selection criteria to ensure experienced operators performed stenting procedures and, indirectly, selected for medical centers with higher overall stenting volumes.…”

Intracranial Hemorrhage Complicating Carotid Artery Stenting and Carotid Endarterectomy

“…In this issue of Stroke, McDonald et al 1 utilize International Classification of Diseases 9 th revision codes from the National Inpatient Sample (NIS) hospital discharge database to study intracranial hemorrhage (ICH), mortality, and discharge disposition after CAS or CEA during 2001 to 2008. This database study illustrates both the power and the weaknesses of such a large retrospective review.…”