Effect of CREST findings on carotid revascularization practice in the United States

Background We sought to measure the impact of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) findings on clinical practice by studying trends in carotid artery stenting (CAS) and carotid endarterectomy (CEA) utilization before and after publication of CREST in a large US multihospital database. Methods The Premier Perspective Database was used to identify inpatient CEA and CAS procedures performed from January 2006 to March 2013. Patients were subclassified by age (<70/≥70 years) and presentation (symptomatic/asymptomatic). CEA and CAS volumes were compared before and after the publication of CREST (July 2010) using an interrupted time series model. Results A total of 121,157 CEA and 18,503 CAS procedures performed at 445 medical centers were identified. There was no significant change observed in the overall number of CEA procedures performed after CREST publication relative to the pre-existing trend (P =.08); however, there was a significant increase in the overall number of CAS procedures performed (delta of 40 cases, P =.0179) in patients aged younger than 70 years (delta of 24 cases, P =.0008), 70 years or older (delta of 25 cases, P =.0047), and asymptomatic patients (delta of 39 cases, P =.0159). The overall percentage of CEA procedures performed in relation to all revascularization procedures was significantly lower after CREST publication overall (delta, -1.5%; P =.041) for patients aged younger than 70 years (delta, -2.4%; P <.0001) and asymptomatic patients (delta, -1.5%; P =.035). Conclusions In this large sample of US hospitals, performance of CAS significantly increased after the publication of the CREST study.