Outcomes and Trends of Carotid Endarterectomy Versus Carotid Artery Stenting with Embolic Protection Device

Abstract

Carotid artery disease is a major cause of ischemic stroke, and its management includes carotid endarterectomy (CEA) and carotid artery stenting (CAS) with embolic protection devices (EPD). While CAS with EPD has gained acceptance, concerns remain regarding periprocedural risks and costs. This study evaluates real-world trends and outcomes of CEA versus CAS with EPD in the United States. Using the 2016 to 2021 National Inpatient Sample, we identified hospitalizations for CEA or CAS with EPD. Primary outcomes included in-hospital mortality and major adverse cardiac and cerebrovascular events (MACCE). Secondary outcomes included perioperative stroke, myocardial infarction (MI), major bleeding, discharge disposition, length of stay, and hospitalization costs. Propensity score matching (1:1) adjusted for baseline differences and multivariable regression compared outcomes. Trends were assessed using the Cochran–Armitage test. Among 405,130 weighted hospitalizations, 403,765 underwent CEA, and 1,365 underwent CAS with EPD. In the matched cohort (1,300 vs. 1,300), CAS with EPD was not associated with higher in-hospital mortality (adjusted odds ratio [aOR]: 0.74; 95% confidence interval [CI]: 0.15–3.62) or MACCE (aOR: 0.91; 95% CI: 0.32–2.62). Stroke, MI, and major bleeding rates were similar. CAS with EPD was linked to shorter hospital stays (β: −0.69; 95% CI: −1.33 to −0.06, p = 0.033) and higher costs (β: +$3,440; 95% CI: $520–$6,350). CAS with EPD utilization increased from 2016 to 2021, whereas CEA declined (p-trend < 0.001). CAS with EPD provides comparable in-hospital safety to CEA, with no significant differences in mortality, MACCE, or perioperative outcomes. Adjusted analysis showed shorter length of stay but higher hospitalization cost.

Keywords

carotid artery stenosis - carotid endarterectomy - carotid artery stenting - embolic protection devices

Ethical Approval

Institutional review board approval and informed consent were not required for this study because the National Inpatient Sample (NIS) is a publicly accessible dataset, and all patient data within the dataset are fully deidentified.

Publication History

Received: 29 September 2025

Accepted: 20 November 2025

Article published online:
28 January 2026

• References

• 1 Qaja E, Tadi P, Theetha Kariyanna P. Symptomatic Carotid Artery Stenosis. FL, United States: StatPearls Treasure Island; 2024
• 2 Müller MD, Bonati LH. Carotid artery stenosis – current evidence and treatment recommendations. J Index Metrics 2021;5:2514183X211001654
• 3 Wabnitz AM, Turan TN. Symptomatic carotid artery stenosis: surgery, stenting, or medical therapy?. Curr Treat Options Cardiovasc Med 2017; 19 (08) 62
• 4 Ferguson GG, Eliasziw M, Barr HW. et al. The North American Symptomatic Carotid Endarterectomy Trial : surgical results in 1415 patients. Stroke 1999; 30 (09) 1751-1758
• 5 Warlow CP. Symptomatic patients: the European Carotid Surgery Trial (ECST). J Mal Vasc 1993; 18 (03) 198-201
• 6 Yadav JS, Wholey MH, Kuntz RE. et al; Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351 (15) 1493-1501
• 7 Ederle J, Bonati LH, Dobson J. et al; CAVATAS Investigators. Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long-term follow-up of a randomised trial. Lancet Neurol 2009; 8 (10) 898-907
• 8 Mantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG, Investigators C. CREST Investigators. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): stenting versus carotid endarterectomy for carotid disease. Stroke 2010; 41 (10, Suppl): S31-S34
• 9 Ringleb PA, Allenberg J, Brückmann H. et al; SPACE Collaborative Group. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368 (9543) 1239-1247
• 10 Paraskevas KI, Zeebregts CJ, AbuRahma AF, Perler BA. Implications of the Centers for Medicare and Medicaid Services decision to expand indications for carotid artery stenting. J Vasc Surg 2024; 80 (03) 599-603
• 11 HCUP National Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 2016. –2019. Agency for Healthcare Research and Quality, Rockville, MD; . Accessed June 30, 2024. www.hcup-us.ahrq.gov/nisoverview.jsp
• 12 HCUP Cost-to-Charge Ratio (CCR) for the National Inpatient Sample. (NIS). Healthcare Cost and Utilization Project (HCUP). 2016. –2021. Agency for Healthcare Research and Quality, Rockville, MD; . Accessed June 30, 2024. www.hcup-us.ahrq.gov/db/ccr/ip-ccr/ip-ccr.jsp
• 13 StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC;
• 14 HCUP Elixhauser Comorbidity Software Refined for ICD-10-CM. v2024.1. Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD; . Accessed June 30, 2024. www.hcup-us.ahrq.gov/toolssoftware/comorbidityicd10/comorbidity_icd10.jsp
• 15 Brott TG, Halperin JL, Abbara S. et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, Society for Vascular Surgery, American Academy of Neurology and Society of Cardiovascular Computed Tomography. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. Stroke 2011; 42 (08) e420-e463
• 16 AbuRahma AF, Avgerinos ED, Chang RW. et al. Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease. J Vasc Surg 2022; 75 (1S): 4S-22S
• 17 Brott TG, Hobson II RW, Howard G. et al; CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363 (01) 11-23
• 18 Bonati LH, Dobson J, Featherstone RL. et al; International Carotid Stenting Study investigators. Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial. Lancet 2015; 385 (9967) 529-538
• 19 Kastrup A, Gröschel K, Krapf H, Brehm BR, Dichgans J, Schulz JB. Early outcome of carotid angioplasty and stenting with and without cerebral protection devices: a systematic review of the literature. Stroke 2003; 34 (03) 813-819
• 20 Zahn R, Mark B, Niedermaier N. et al; Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK). Embolic protection devices for carotid artery stenting: better results than stenting without protection?. Eur Heart J 2004; 25 (17) 1550-1558
• 21 Bonati LH, Kakkos S, Berkefeld J. et al. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6: I
• 22 Halliday A, Bulbulia R, Bonati LH. et al; ACST-2 Collaborative Group. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet 2021; 398 (10305): 1065-1073
• 23 Centers for Medicare & Medicaid Services. National coverage determination for percutaneous transluminal angioplasty (PTA). 2021 . Accessed March 1, 2025. https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=201
• 24 Sridharan ND, Chaer RA, Smith K, Eslami MH. Carotid endarterectomy remains cost-effective for the surgical management of carotid stenosis. J Vasc Surg 2022; 75 (04) 1304-1310