With the recent expansion of the Centers for Medicare and Medicaid Services coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. Because approximately 30% of perioperative strokes/deaths post-CAS occur after discharge, appropriate thresholds for in-hospital event rates have been suggested to be <4% for symptomatic and <2% for asymptomatic patients. This study evaluates the tfCAS learning curve using Vascular Quality Initiative (VQI) data. We identified VQI patients who underwent tfCAS between 2005 and 2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. The primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/myocardial infarction (MI), 30-day mortality, in-hospital stroke/transient ischemic attack (stroke/TIA), and access site complications. The relationship between outcomes and procedure counts was analyzed using the Cochran-Armitage test and a generalized linear model with restricted cubic splines. Our results were then validated using a generalized estimating equations model to account for the variability between physicians. We analyzed 43,147 procedures by 2476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2%-1.7%), in-hospital stroke/death/MI (5.8%-1.7%), 30-day mortality (4.6%-2.8%), in-hospital stroke/TIA (5.0%-1.1%), and access site complications (4.1%-1.1%) as physician experience increased (all values < .05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1%-1.6%), in-hospital stroke/death/MI (2.6%-1.6%), 30-day mortality (1.7%-0.4%), and in-hospital stroke/TIA (2.8%-1.6%) with increasing physician experience (all values <.05). The in-hospital stroke/death rate remained above 2% until 13 procedures. In-hospital stroke/death and 30-day mortality rates after tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. Nevertheless, a substantially high rate of in-hospital stroke/death was found in physicians' first 25 procedures. With the recent Centers for Medicare and Medicaid Services coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased postoperative complications.

中文翻译：

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血管质量倡议登记处经股颈动脉支架置入术的学习曲线

随着最近医疗保险和医疗补助服务中心覆盖范围的扩大，经股颈动脉支架置入术（tfCAS）预计将在颈动脉疾病的治疗中发挥更大的作用。现有的 tfCAS 学习曲线研究主要在十多年前进行，可能无法充分描述当前医生经验对结果的影响。由于大约 30% 的 CAS 围手术期卒中/死亡发生在出院后，因此建议有症状患者的院内事件发生率的适当阈值小于 4%，无症状患者小于 2%。本研究使用血管质量倡议 (VQI) 数据评估 tfCAS 学习曲线。我们确定了 2005 年至 2023 年间接受 tfCAS 的 VQI 患者。每位医生的手术按时间顺序分为 12 个类别，从手术计数 1-25 到 351+。主要结局是院内卒中/死亡率；次要结局是院内卒中/死亡/心肌梗死 (MI)、30 天死亡率、院内卒中/短暂性脑缺血发作 (卒中/TIA) 以及通路部位并发症。使用 Cochran-Armitage 检验和具有受限三次样条的广义线性模型分析结果和程序计数之间的关系。然后使用广义估计方程模型验证我们的结果，以解释医生之间的差异。我们分析了 2476 名医生的 43,147 例手术。在有症状的患者中，院内卒中/死亡（手术计数 1-25 至 351+：5.2%-1.7%）、院内卒中/死亡/心肌梗死（5.8%-1.7%）、随着医生经验的增加，30 天死亡率 (4.6%-2.8%)、院内卒中/TIA (5.0%-1.1%) 和穿刺部位并发症 (4.1%-1.1%)（所有值 < 0.05）。在 235 次手术之前，院内卒中/死亡率一直保持在 4% 以上。同样，在无症状患者中，院内卒中/死亡 (2.1%-1.6%)、院内卒中/死亡/心肌梗死 (2.6%-1.6%)、30 天死亡率 (1.7%) 均有所下降-0.4%)，以及随着医生经验的增加，院内卒中/TIA (2.8%-1.6%)（所有值 <.05）。院内卒中/死亡率在 13 次手术之前一直保持在 2% 以上。随着医生经验的增加，tfCAS 后的院内卒中/死亡和 30 天死亡率下降，显示出与之前报告一致的漫长学习曲线。鉴于医生的早期病例可能不包含在 VQI 中，学习曲线可能被低估。然而，在医生的前 25 次手术中发现院内中风/死亡的比例相当高。随着最近医疗保险和医疗补助服务中心对 tfCAS 覆盖范围的扩大，大量医生将进入学习曲线的早期阶段，这可能导致术后并发症增加。