In little more than a decade, the use of carotid stenting for prevention of cerebrovascular events has grown greatly. In 1998, roughly 0.1 per 1000 Medicare beneficiaries per year received a carotid stenting procedure. By 2007, that number had increased to 0.6 procedures per 1000 beneficiaries per year.1 Overall rates of carotid revascularization decreased during this period, suggesting that carotid stenting was substituted for carotid endarterectomy (CEA). Even more dramatically, coincident with widespread Medicare coverage of carotid stenting beginning in October 2004, there was a quadrupling of procedures in 2 years.2 From 2004 to 2006, the number of stenting procedures increased from a mean of 266 per month to 1015 per month. Furthermore, prior to widespread Medicare coverage, 82% of carotid stent recipients had a diagnosis of prior transient ischemic attack (TIA) (3756 of 4590), while in the era after widespread coverage only 23% (1216 of 5354) had a diagnosis of prior TIA. This change suggests an increased rate of implant procedures in asymptomatic patients. In fact, some authors estimate that 70% to 90%3 of carotid stents are now being placed in asymptomatic patients. We believe the increase in carotid stenting procedures at the expense of CEA, as well as the number of asymptomatic patients treated, to be concerning for several reasons.
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