A Contemporary Evaluation of the Centers for Medicare and Medicaid Services High-risk Indicators for Carotid Endarterectomy

Objective:Compare stroke/death outcomes across carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) using Centers for Medicare and Medicaid Services (CMS) high-risk criterion. Background:Existing literature has revealed inconsistencies with CMS risk guidelines. With recent approval for TCAR and TFCAS in standard-risk patients, an updated analysis of guidelines is needed. Methods:Data from the Vascular Quality Initiative (VQI) (2016-2023) on CEA, TFCAS, or TCAR patients were used. We used inverse probability of treatment weighting to compare in-hospital stroke/death rates across procedures for high-risk criteria: contralateral occlusion (CLO), prior CEA, CAS, radiation, neck surgery, moderate to severe CHF, severe COPD (on home O2), unstable angina, recent MI (<6 mo), and age (>= 75 years-old). Results:A total of 199,050 patients were analyzed, of whom 122,737 (62%) patients underwent CEA, 50,095 (25%) TCAR, and 26,218 (13%) TFCAS. TCAR had lower odds of stroke/death compared with CEA in patients with CLO [aOR=0.73 (95% CI: 0.55-0.98], P=0.035] and radiation [aOR=0.44 (95% CI: 0.23-0.82), P=0.010]. Contrary to CMS criteria, CEA patients did not have higher stroke/death in patients with prior CEA, CAS, neck surgery, moderate to severe CHF, severe COPD, unstable angina, recent MI, or age (>= 75) compared with TCAR and TFCAS. Conclusions:While CMS high-risk criteria have traditionally been recognized as contraindications for CEA, our study reveals inconsistencies-with CEA performing similarly to TCAR and significantly better than TFCAS in patients with prior CEA, moderate to severe CHF, recent MI, or age (>= 75). As a result, the definition of high-risk criteria may warrant reconsideration.