Limits...
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.


Operator specialty-specific rates of carotid endarterectomy (A) and stenting (B). 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
getmorefigures.php?uid=PMC5120767&req=5

Figure 4: Operator specialty-specific rates of carotid endarterectomy (A) and stenting (B). These rates (per 100 000 adults ≥40 years old) are reported for 3-month periods from April 1, 2002, to March 31, 2014.

Mentions: Rates of carotid revascularization by operator specialty over the study period also varied (Figure 4). Vascular surgeons most commonly performed endarterectomy, and this rate remained relatively stable between 2002 and 2014 (from 2.3 to 2.5 procedures per 100 000; P=0.13). The rate of carotid endarterectomy performed by general surgeons did not change significantly either (P=0.52), whereas cardiac surgeons and neurosurgeons performed significantly less endarterectomy (both P<0.001). In fact, cardiac surgeons stopped performing carotid endarterectomy in 2009, whereas neurosurgeons were performing 64% less endarterectomy (from 1.6 to 0.6 procedures per 100 000) by the end of the study period. Neurosurgeons, however, performed nearly 4× more carotid-artery stenting (from 0.06 to 0.22 procedures per 100 00; P<0.001), which was second only to carotid-artery stenting performed by radiologists (62% increase; from 0.28 to 0.45 procedures per 100 00; P<0.001).


Impact of Clinical Trial Results on the Temporal Trends of Carotid Endarterectomy and Stenting From 2002 to 2014
Operator specialty-specific rates of carotid endarterectomy (A) and stenting (B). 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 4: Operator specialty-specific rates of carotid endarterectomy (A) and stenting (B). These rates (per 100 000 adults ≥40 years old) are reported for 3-month periods from April 1, 2002, to March 31, 2014.
Mentions: Rates of carotid revascularization by operator specialty over the study period also varied (Figure 4). Vascular surgeons most commonly performed endarterectomy, and this rate remained relatively stable between 2002 and 2014 (from 2.3 to 2.5 procedures per 100 000; P=0.13). The rate of carotid endarterectomy performed by general surgeons did not change significantly either (P=0.52), whereas cardiac surgeons and neurosurgeons performed significantly less endarterectomy (both P<0.001). In fact, cardiac surgeons stopped performing carotid endarterectomy in 2009, whereas neurosurgeons were performing 64% less endarterectomy (from 1.6 to 0.6 procedures per 100 000) by the end of the study period. Neurosurgeons, however, performed nearly 4× more carotid-artery stenting (from 0.06 to 0.22 procedures per 100 00; P<0.001), which was second only to carotid-artery stenting performed by radiologists (62% increase; from 0.28 to 0.45 procedures per 100 00; P<0.001).

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.