Complication rates and center enrollment volume in the carotid revascularization endarterectomy versus stenting trial

Nicole R Gonzales, Bart M Demaerschalk, Jenifer H Voeks, MeeLee Tom, George Howard, Alice J Sheffet, Lawrence Garcia, Daniel G Clair, John Barr, Steven Orlow, Thomas G Brott, CREST Investigators, Nicole R Gonzales, Bart M Demaerschalk, Jenifer H Voeks, MeeLee Tom, George Howard, Alice J Sheffet, Lawrence Garcia, Daniel G Clair, John Barr, Steven Orlow, Thomas G Brott, CREST Investigators

Abstract

Background and purpose: Evidence indicates that center volume of cases affects outcomes for both carotid endarterectomy and stenting. We evaluated the effect of enrollment volume by site on complication rates in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST).

Methods: The primary composite end point was any stroke, myocardial infarction, or death within 30 days or ipsilateral stroke in follow-up. The 477 approved surgeons performed >12 procedures per year with complication rates <3% for asymptomatic patients and <5% for symptomatic patients; 224 interventionists were certified after a rigorous 2 step credentialing process. CREST centers were divided into tertiles based on the number of patients enrolled into the study, with Group 1 sites enrolling <25 patients, Group 2 sites enrolling 25 to 51 patients, and Group 3 sites enrolling >51 patients. Differences in periprocedural event rates for the primary composite end point and its components were compared using logistic regression adjusting for age, sex, and symptomatic status within site-volume level.

Results: The safety of carotid angioplasty and stenting and carotid endarterectomy did not vary by site-volume during the periprocedural period as indicated by occurrence of the primary end point (P=0.54) or by stroke and death (P=0.87). A trend toward an inverse relationship between center enrollment volume and complications was mitigated by adjustment for known risk factors.

Conclusions: Complication rates were low in CREST and were not associated with center enrollment volume. The data are consistent with the value of rigorous training and credentialing in trials evaluating endovascular devices and surgical procedures.

Clinical trial registration url: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.

Keywords: carotid endarterectomy; carotid stenosis; randomized controlled trial; stenting; stroke; training.

Conflict of interest statement

CONFLICT OF INTEREST DISCLOSURE

N. R. Gonzales - None

B. M. Demaerschalk - None

J. H. Voeks - None

M. Tom - None

G. Howard - None

L. Garcia - None

D. Clair – Consultant: Arsenal Medical, Confluent, Endologix, Vessix Vascular, Volcano Corp.; DSMB member: Bard; Advisory Board: Boston Scientific, Medtronic

J. Barr – Shareholder: Boston Scientific, Medtronic; Consultant: Covidien

S. Orlow - None

T. G. Brott - None

© 2014 American Heart Association, Inc.

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