{"id":12056,"date":"2011-09-27T16:14:38","date_gmt":"2011-09-27T20:14:38","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=news&#038;p=12056"},"modified":"2011-09-27T16:21:11","modified_gmt":"2011-09-27T20:21:11","slug":"experience-counts-in-carotid-artery-stenting","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2011\/09\/27\/experience-counts-in-carotid-artery-stenting\/","title":{"rendered":"Experience Counts in Carotid Artery Stenting"},"content":{"rendered":"<p>According to <a href=\"http:\/\/jama.ama-assn.org\/content\/306\/12\/1338.abstract\">a new study published in\u00a0<\/a><em><a href=\"http:\/\/jama.ama-assn.org\/content\/306\/12\/1338.abstract\">JAMA<\/a>, <\/em>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.<\/p>\n<p>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.<\/p>\n<p>Here are 30-day mortality rates and adjusted odds ratios based on annual volume of operator:<\/p>\n<ul>\n<li>High-volume operator ( \u226524 procedures): 71 deaths out of 5127 procedures, OR 1 (reference)<\/li>\n<li>Medium-volume operator (12-23 procedures): 114\/7059, OR 1.2 (p=0.30)<\/li>\n<li>Low-volume operator (6-11 procedures): 109\/5752, OR 1.4 (p=0.06)<\/li>\n<li>Very-low-volume operator (&lt;6 procedures): 167\/6763, OR 1.9 (p&lt;0.001)<\/li>\n<\/ul>\n<p>Lower-volume operators were also much less likely to use embolic protection devices than higher-volume operators.<\/p>\n<p>In<a href=\"http:\/\/jama.ama-assn.org\/content\/306\/12\/1378.extract\"> an accompanying editorial<\/a>, 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 &#8220;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.&#8221;<\/p>\n<p>Although the current study shows that\u00a0\u201cpractice makes perfect,\u201d he writes, &#8220;it may be that some physicians are &#8216;practicing too much.&#8217; 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.&#8221;<\/p>\n<p><em>CardioExchange&#8217;s Interventional Cardiology moderators, Rick Lange and David Hillis, posed some great questions to the lead author of the <\/em>JAMA<em> study. Click <a href=\"http:\/\/blogs.nejm.org\/cardioexchange\/expert-is-in\/carotid-stenting-how-steep-the-learning-curve\/\">here <\/a>to read their interview and ask questions of your own.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Experience really does count when it comes to carotid artery stenting, and that may be a big problem, since most current operators do not have substantial experience with the procedure.<\/p>\n","protected":false},"author":196,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9,16],"tags":[994,995],"class_list":["post-12056","post","type-post","status-publish","format-standard","hentry","category-interventional-cardiology","category-vascular","tag-carotid-artery-stenting","tag-operator-experience"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/12056","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/196"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=12056"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/12056\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=12056"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=12056"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=12056"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}