Abstract Details

In July 2023, the Center for Medicare and Medicaid Services (CMS) proposed broader coverage for CAS for patients with symptomatic (Sx) and asymptomatic carotid disease (Asx) in the US.

The study provides a 15-year snapshot of contemporary carotid artery stenting (CAS) and carotid endarterectomy (CEA) use in various age/sex groups of the United States (US).

We identified all Sx and Asx CAS and CEA admissions in adults (>=18 years) from the 2006-2020 National Inpatient Sample using International-Classification-of-Diseases codes.  We calculated the age and sex-specific proportions of revascularizations that were CAS and combined annual CAS/CEA counts with census data to determine annual utilization rate/100,000 population. We used Joinpoint regression to estimate annualized percentage change (APC) in usage over time.

Of 1,591,651 weighted procedures from 2006-2020, 30% were in  60-69-year-olds and 20% in >=80-year-olds. This age distribution was constant over time. 15.1% of all procedures were CAS but this proportion doubled over time such that in 2020, 29.6% of all procedures were CAS. CAS proportion increased in all age groups including >70-year-olds and women, even after excluding patients with tandem occlusions. 22.5% of CAS and 11.7% of CEA were done in Sx patients but this proportion increased over time in both CAS and CEA (p-trend <0.001). Annual usage of CEA declined from 51.6 to 22.5 cases/100,000 population in both sexes combined (APC -5.4%, 95%CI -6.0 to -4.8), while CAS use declined from 2006-2016 but increased significantly over 2016-2020 in both men (APC 16.5%, 95%CI 10.0 to 23.3) and women (APC 15.2%, 95%CI 10.2 to 20.4).

Despite uncertain benefit in selected age and sex groups including Sx women and  >70year-olds, CAS use has continued to increase in all age and sex groups and now accounts for one-third  of carotid revascularizations in the US.  With the CMS change CAS use could increase further.