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Impact of Clinical Trial Results on the Temporal Trends of Carotid Endarterectomy and Stenting From 2002 to 2014

View Article: PubMed Central - PubMed

ABSTRACT

Background and purpose—: Randomized trials provide conflicting data for the efficacy of carotid-artery stenting compared with endarterectomy. The purpose of this study was to examine the impact of conflicting clinical trial publications on the utilization rates of carotid revascularization procedures.

Methods—: We conducted a population-level time-series analysis of all individuals who underwent carotid endarterectomy and stenting in Ontario, Canada (2002–2014). The primary analysis examined temporal changes in the rates of carotid revascularization procedures after publications of major randomized trials. Secondary analyses examined changes in overall and age, sex, carotid-artery symptom, and operator specialty–specific procedure rates.

Results—: A total of 16 772 patients were studied (14 394 endarterectomy [86%]; 2378 stenting [14%]). The overall rate of carotid revascularization decreased from 6.0 procedures per 100 000 individuals ≥40 years old in April 2002 to 4.3 procedures in the first quarter of 2014 (29% decrease; P<0.001). The rate of endarterectomy decreased by 36% (P<0.001), whereas the rate of carotid-artery stenting increased by 72% (P=0.006). We observed a marked increase (P=0.01) in stenting after publication of the SAPPHIRE trial (Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy) in 2004, whereas stenting remained relatively unchanged after subsequent randomized trials published in 2006 (P=0.11) and 2010 (P=0.34). In contrast, endarterectomy decreased after trials published in 2006 (P=0.04) and 2010 (P=0.005).

Conclusions—: Although the overall rates of carotid revascularization and endarterectomy have fallen since 2002, the rate of carotid-artery stenting has risen since the publication of stenting-favorable SAPPHIRE trial. Subsequent conflicting randomized trials were associated with a decreasing rate of carotid endarterectomy.

No MeSH data available.


Trends in the rates of carotid endarterectomy and stenting by symptomatic status. These rates (per 100 000 adults ≥40 years old) are reported for 3-month periods from April 1, 2002, to March 31, 2014.
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Figure 3: Trends in the rates of carotid endarterectomy and stenting by symptomatic status. These rates (per 100 000 adults ≥40 years old) are reported for 3-month periods from April 1, 2002, to March 31, 2014.

Mentions: In regard to temporal trends by carotid-artery symptoms, we found that carotid endarterectomy was being performed less frequently in both symptomatic (43% decrease; from 2.8 to 1.6 procedures per 100 000; P=0.003) and asymptomatic patients (28% decrease; from 2.8 to 2.0 procedures per 100 000; P<0.001; Figure 3). Interestingly, endarterectomy for asymptomatic stenosis initially increased from 2002 to the last quarter of 2006, at which point it was being performed more than twice as frequently for asymptomatic (4.1 procedures per 100 000) compared with symptomatic (2.0 procedures per 100 000) stenosis. Beginning in 2008, however, there was a rapid decline in endarterectomy for asymptomatic carotid stenosis, whereas the rate of endarterectomy for symptomatic stenosis remained relatively stable. Carotid-artery stenting, on the contrary, increased among both symptomatic (76% increase; from 0.22 to 0.39 procedures per 100 000; P<0.001) and asymptomatic (65% increase; from 0.17 to 0.27 procedures per 100 000; P<0.001) patients during the study period.


Impact of Clinical Trial Results on the Temporal Trends of Carotid Endarterectomy and Stenting From 2002 to 2014
Trends in the rates of carotid endarterectomy and stenting by symptomatic status. These rates (per 100 000 adults ≥40 years old) are reported for 3-month periods from April 1, 2002, to March 31, 2014.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5120767&req=5

Figure 3: Trends in the rates of carotid endarterectomy and stenting by symptomatic status. These rates (per 100 000 adults ≥40 years old) are reported for 3-month periods from April 1, 2002, to March 31, 2014.
Mentions: In regard to temporal trends by carotid-artery symptoms, we found that carotid endarterectomy was being performed less frequently in both symptomatic (43% decrease; from 2.8 to 1.6 procedures per 100 000; P=0.003) and asymptomatic patients (28% decrease; from 2.8 to 2.0 procedures per 100 000; P<0.001; Figure 3). Interestingly, endarterectomy for asymptomatic stenosis initially increased from 2002 to the last quarter of 2006, at which point it was being performed more than twice as frequently for asymptomatic (4.1 procedures per 100 000) compared with symptomatic (2.0 procedures per 100 000) stenosis. Beginning in 2008, however, there was a rapid decline in endarterectomy for asymptomatic carotid stenosis, whereas the rate of endarterectomy for symptomatic stenosis remained relatively stable. Carotid-artery stenting, on the contrary, increased among both symptomatic (76% increase; from 0.22 to 0.39 procedures per 100 000; P<0.001) and asymptomatic (65% increase; from 0.17 to 0.27 procedures per 100 000; P<0.001) patients during the study period.

View Article: PubMed Central - PubMed

ABSTRACT

Background and purpose—: Randomized trials provide conflicting data for the efficacy of carotid-artery stenting compared with endarterectomy. The purpose of this study was to examine the impact of conflicting clinical trial publications on the utilization rates of carotid revascularization procedures.

Methods—: We conducted a population-level time-series analysis of all individuals who underwent carotid endarterectomy and stenting in Ontario, Canada (2002&ndash;2014). The primary analysis examined temporal changes in the rates of carotid revascularization procedures after publications of major randomized trials. Secondary analyses examined changes in overall and age, sex, carotid-artery symptom, and operator specialty&ndash;specific procedure rates.

Results—: A total of 16&thinsp;772 patients were studied (14&thinsp;394 endarterectomy [86%]; 2378 stenting [14%]). The overall rate of carotid revascularization decreased from 6.0 procedures per 100&thinsp;000 individuals &ge;40 years old in April 2002 to 4.3 procedures in the first quarter of 2014 (29% decrease; P&lt;0.001). The rate of endarterectomy decreased by 36% (P&lt;0.001), whereas the rate of carotid-artery stenting increased by 72% (P=0.006). We observed a marked increase (P=0.01) in stenting after publication of the SAPPHIRE trial (Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy) in 2004, whereas stenting remained relatively unchanged after subsequent randomized trials published in 2006 (P=0.11) and 2010 (P=0.34). In contrast, endarterectomy decreased after trials published in 2006 (P=0.04) and 2010 (P=0.005).

Conclusions—: Although the overall rates of carotid revascularization and endarterectomy have fallen since 2002, the rate of carotid-artery stenting has risen since the publication of stenting-favorable SAPPHIRE trial. Subsequent conflicting randomized trials were associated with a decreasing rate of carotid endarterectomy.

No MeSH data available.