Trends in the Utilization of Different Carotid Revascularization Modalities in the United States Over a 17-Year Period

In October 2023, the Centers for Medicare & Medicaid Services (CMS) in the United States expanded coverage for carotid artery stenting (CAS) to include non-high-risk patients with carotid disease. The aim of this study was to provide a 17-year snapshot of trends in carotid revascularization practices in the United States before this CMS policy change went into effect. We conducted a serial cross-sectional study using the 2006-2022 National Inpatient Sample and a retrospective cohort study using the State Emergency and Inpatient Databases of Florida (2005-2021), Georgia (2010-2020), Maryland (2012-2021), and New York (2005-2020). Cases of carotid revascularizations in these databases were identified using International Classification of Diseases codes. We calculated age-specific and sex-specific proportions of revascularizations for CAS and combined annual CAS/carotid endarterectomy (CEA) counts with census data to determine utilization rates per 100,000 population. Joinpoint regression estimated annualized percentage change (APC) over time. Hospitalizations in the 6 months preceding revascularization defined symptomatic vs asymptomatic cases and characterized the subset with symptomatic stenosis. Of 1,779,948 weighted revascularizations, the mean patient age was 71.0 years and 40.9% were performed in women. 17.2% of procedures were CAS, and this proportion more than doubled from 14.3% to 29.0%. Transcarotid artery revascularization accounted for 9.1% in 2022. The CAS proportion increased across age groups, including in those aged older than 70 years and in women, even after excluding mechanical thrombectomy admission. Carotid revascularization usage per 100,000 population declined (APC -3.9%, 95% CI -4.1% to -3.3%) but plateaued after 2015. Although CEA utilization declined from 2006 to 2022 (APC -5.5%, 95% CI -5.9% to -5.1%), CAS use declined from 2006 to 2016 (APC -3.2%, 95% CI -4.6% to -2.1%) but increased from 2016 to 2022 (APC 12.0%, 95% CI 10.1%-14.1%). Only 25.7% of revascularizations in the 4 states were performed for symptomatic disease, with 75.3% of hospitalizations in women for asymptomatic disease. Despite uncertain benefit in selected age and sex groups, including those older than 70 years and with asymptomatic carotid disease, CAS use increased across groups over the past decade and now accounts for >25% of carotid revascularizations in the United States.