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A Single Center’s 30-day Outcomes are Comparable to those Established in CREST and Support the Use of Both Stenting and Endarterectomy by Vascular Surgeons
Joshua C Grimm, Isibor Arhuidese, Robert J Beaulieu, Umair Qazi, Julie A Freischlag, Bruce A Perler, Mahmoud Malas
The Johns Hopkins Medical Institution, Baltimore, MD

INTRODUCTION:
While CREST has been widely accepted as a landmark trial establishing an equivocal risk of major adverse events (MAEs) following carotid endarterectomy (CEA) or carotid artery stenting (CAS), the applicability of these findings to single centers has been questioned due to the rigid selection criteria for investigators in the study. Furthermore, a sub-study of CREST established higher peri-procedural stroke rate for CAS, in comparison to CEA, when the operator was a vascular surgeon. Accordingly, we present our 30-day results of stroke, death, myocardial infarction (MI) and composite events to determine the durability of CREST’s conclusions when performed by a vascular surgeon at one institution.
METHODS:
A retrospective analysis was undertaken of all data collected between 2005 and 2013 on patients with high-grade carotid artery stenosis, treated with carotid endarterectomy (CEA) or carotid artery stenting (CAS) by a vascular surgeon at our institution. Chi-squared analysis was utilized to compare the incidence of specific high risk patient characteristics in each group (CEA v. CAS). Fisher’s Exact Test was employed to compare the risks of stroke, death, MI and composite MAEs between CEA and CAS. These results were then evaluated against those documented in CREST.
RESULTS:
A total of 182 cases (94 CAS and 88 CEA) performed by a single vascular surgeon were included for analysis. While the peri-procedural risks of stroke and MI were higher in CREST following CAS and CEA, respectively, our findings did not corroborate these outcomes as there was no significant difference between the two interventions in our cohort. When compared to CREST, our rates of MI, stroke, death, and composite events were no different. Table 1 details the outcomes at our institution and in the CREST population.
CONCLUSIONS:
Similar to CREST, the 30-day risk of composite MAEs at our institution was equivalent for the two treatment modalities. We attribute our comparable incidence of peri-operative stroke in CAS and CEA to improved patient selection by excluding most octogenarians and as well as patients with complex anatomy. Our results affirm those attained in CREST and support the practice of performing both CEA and CAS by experienced vascular surgeons.
CEA vs. CAS at Single Institution and in Comparison to CREST
Single Center
CEA
(n=88)
Single Center
CAS
(n=94)
p-valueCREST
CEA
n=1240
CREST
CAS
n=1262
p-value
Stroke2 (2.3%)1 (1.1%)0.6129 (2.3%)52 (4.1%)0.001
Death0 (0%)1 (1.1%)1.004 (0.3%)9 (0.7%)0.26
MI1 (1.1%)2 (2.1%)1.0028 (2.3%)14 (1.1%)0.02
Combined MAE3 (3.3%)4 (4.3%)1.0056 (4.5%)66 (5.2%)0.45
Single Center
CEA
(n=88)
CREST
CEA
(n=1240)
p-valueSingle Center
CAS
(n=94)
CREST
CAS
(n=1262)
p-value
Stroke2 (2.3%)29 (2.3%)1.001 (1.1%)52 (4.1%)0.17
Death0 (0%)4 (0.3%)1.001 (1.1%)9 (0.7%)0.51
MI1 (1.1%)28 (2.3%)0.722 (2.1%)14 (1.1%)0.31
Combined MAE3 (3.3%)56 (4.5%)0.794 (4.3%)66 (5.2%)1.00


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