CardioExchange Archive

According to a new study published in JAMA, experience really does count when it comes to carotid artery stenting (CAS). And that may be a big problem, since the explosive growth in the procedure after gaining FDA approval in 2004 means that most current operators do not have substantial experience with the procedure.

Brahmajee Nallamothu and colleagues analyzed Medicare data from 24,701 CAS procedures performed between 2005 and 2007. The overall 30-day mortality rate was 1.9%, but there was a significant increase in the risk for death among patients treated by the lowest-volume operators.

Here are 30-day mortality rates and adjusted odds ratios based on annual volume of operator:

• High-volume operator ( ≥24 procedures): 71 deaths out of 5127 procedures, OR 1 (reference)
• Medium-volume operator (12-23 procedures): 114/7059, OR 1.2 (p=0.30)
• Low-volume operator (6-11 procedures): 109/5752, OR 1.4 (p=0.06)
• Very-low-volume operator (<6 procedures): 167/6763, OR 1.9 (p<0.001)

Lower-volume operators were also much less likely to use embolic protection devices than higher-volume operators.

In an accompanying editorial, Ethan Halm expresses concern about the growing use of CAS, especially for elderly patients and asymptomatic patients. The 1.9% mortality rate in the study is substantially higher than the 0.7% in CREST. He writes that “relatively high complication rates in real-world practice would substantially reduce and perhaps completely eliminate any long-term expected benefit of revascularization, especially among asymptomatic patients who have much less to gain from the procedure.”

Although the current study shows that “practice makes perfect,” he writes, “it may be that some physicians are ‘practicing too much.’ A procedure performed in a patient who would not be expected to benefit from it is inappropriate and wasteful regardless of how skilled the operator or how low the complication rate.”

CardioExchange’s Interventional Cardiology moderators, Rick Lange and David Hillis, posed some great questions to the lead author of the JAMA study. Click here to read their interview and ask questions of your own.