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

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.