Evolving Trends in Carotid Endarterectomy and Stenting in Australia: A 15-Year Analysis in the Post-CREST Era

Background: Stroke remains a leading cause of mortality in Australia. Over the past three decades, carotid endarterectomy (CEA) has been the gold standard for stroke prevention in patients with symptomatic high-grade carotid stenosis. Carotid artery stenting (CAS) has emerged as a minimally invasive alternative, particularly for high-risk surgical candidates. This study aims to evaluate national trends in CEA and CAS in Australia over a 15-year period, reflecting evolving practices in the post-CREST era. Methods: A population-level retrospective trend analysis was conducted using Australian Institute of Health and Welfare Procedures Data Cubes to identify CEA and CAS procedures performed between 2009 and 2023. Population-adjusted incidence rates were calculated using data from the Australian Bureau of Statistics. Simple linear regression analysis was used to assess changes in procedure rates overtime. Results: A total of 41,845 carotid interventions were performed during the study period, with males accounting for 70.47% of procedures. CEA comprised the majority of interventions (78.86%), while CAS accounted for 21.14%. The population-adjusted incidence of CEA declined significantly by 0.346 procedures per 100,000 people annually (p < 0.001), consistent across all age groups and genders. Conversely, CAS incidence increased modestly by 0.061 procedures per 100,000 people annually (p = 0.044), with the most significant rise observed in patients aged 60– 69 years. Conclusion: This study highlights significant changes in carotid revascularisation practices in Australia, with a marked decline in revascularisation procedures overall, primarily driven by a significant decline in CEA overtime. CAS showed a modest but significant increase over the study period. These findings align with global trends, reflecting the impact of improved medical management, shifting clinical guidelines, and the growing role of minimally invasive techniques. Future research should investigate the clinical outcomes and indications associated with these trends to optimise patient selection and refine management strategies for carotid artery disease.