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Carotid Stenting: What Have You Done for Me Lately?

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Science Translational Medicine  26 Feb 2014:
Vol. 6, Issue 225, pp. 225ec35
DOI: 10.1126/scitranslmed.3008708

Olympic athletes know that the more you do something, the better you get. This dictum applies not only to riding the half-pipe and mastering a triple axel, but also to the minimally invasive placement of stents in patients to open their narrowed carotid arteries. Calvet and colleagues report that outcomes after carotid artery stenting procedures were related to the number of stents inserted by a surgeon (the “operator”) over a 1-year period (called the annual in-trial procedural volume).

The investigators conducted a pooled analysis of individual patient data from three large European randomized clinical trials of stenting versus endarterectomy—surgical opening of the carotid artery—as treatments for symptomatic carotid stenosis. They examined the impact of the operator’s lifetime carotid stenting experience, in-trial volume, and lifetime experience in stenting vessels aside from the carotid artery. A multivariate analysis was used to determine the association between each procedural volume determinant (analyzed categorically in tertiles) and patient outcome. Estimates were adjusted for potential confounders, such as age, gender, and contralateral severe carotid stenosis or occlusion.

The 30-day risk of stroke or death was significantly higher in patients treated by surgeons with low (mean ≤3.2 procedures/year) or intermediate (3.2 to 5.6 procedures/year) in-trial volumes when compared with patients treated by surgeons with high annual in-trial volumes (>5.6 procedures/year). Outcome was not affected by operator lifetime carotid stenting experience and lifetime experience stenting vessels aside from the carotid artery.

This study illustrates an association between annual operator volume and patient outcome after carotid artery stenting procedures. Only a minority of operators in this trial (36%) performed more than 5.6 procedures each year. The findings imply potential benefits to procedural regionalization at such centers with high operator volumes. As with many technical exercises, it appears that recent volume and operator experience affect results. In other words, it’s not how many procedures your surgeon has performed in the past, but how many he or she has performed lately.

D. Calvet et al., Carotid stenting: Is there an operator effect? Pooled analysis from the carotid stenting trialists’ collaboration. Stroke 45, 527–532 (2014). [Abstract]

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