CREST: Stenting, endarterectomy fairly equal in safety, efficacy for carotid stenosis
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The safety and efficacy results of treating carotid stenosis with either endarterectomy or stenting are roughly equivalent, based on the much-anticipated CREST trial, presented at the 2010 International Stroke Conference in San Antonio on Feb. 26. However, questions remain about stenting elderly patients with carotid stenosis.

The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST), led by investigators at Mayo Clinic, Jacksonville, Fla., and the University of Medicine and Dentistry of New Jersey in Newark, followed 2,502 participants at 117 centers in the U.S. and Canada over a nine-year period. Carotid endarterectomy (CEA), a surgical procedure to clear blocked bloodflow, was compared to carotid artery stenting (CAS). CEA has been the traditional gold standard treatment.

The overall safety and efficacy of the two procedures were largely the same with equal benefits for both men and women, and for patients who had previously had or did not have a stroke, according to the researchers.

However, when the investigators looked at the numbers of heart attacks and strokes, they found differences. The investigators found that in the weeks following the procedure, there were more heart attacks in the surgical group than in the stenting group: 2.3 percent compared to 1.1 percent; and more strokes in the stenting group than the surgery group: 4.1 percent versus 2.3 percent.

The study also found that the age of the patient made a difference. At approximately age 69 and younger, stenting results were slightly better, with a larger benefit for stenting, the younger the age of the patient. Conversely, for patients older than 70, surgical results were slightly superior to stenting, with larger benefits for surgery, the older the age of the patient.

“The CREST trial results show that we now have two safe and effective methods to treat carotid artery disease directly, the tried and true CEA, and the new kid on the block, CAS," said U.S. principal investigator Thomas G. Brott, MD, professor of neurology and director for research at Mayo Clinic in Jacksonville, Fla. “There was evidence that people who were younger than 70 did better with stents while those over 70 had better results with the surgery, but the results for all men and women were excellent.”

"The CREST trial provides doctors and patients with much needed risk/benefit information to help choose the best carotid procedure based on an individual's health history. This personalized decision making should translate into improved patient outcomes," said Walter J. Koroshetz, MD, deputy director of the National Institute of Neurological Disorders and Stroke (NINDS), which funded the trial.

As a result, the pivotal differences were the lower rate of stroke following surgery and the lower rate of heart attack following stenting, according to the investigators. A year after the procedure, the patients who had suffered a stroke reported that the effects of the stroke had a greater impact on their quality of life than was reported by those patients who had suffered a heart attack.

The average age of the patients in this trial was 69. "These patients have many good years ahead of them, and that’s why the lessons learned from CREST are so important. People have some very good options for stroke prevention that we hope will not only extend the length but also the quality of their lives," said Brott.

The CREST investigators concluded that while CEA has a proven record and long term durability, both CAS and CEA are safe and useful tools in the right setting for stroke prevention, and technology continues to improve each procedure.

In addition to the NINDS, Abbott of Abbott Park, Ill., provided partial funding for the study.