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CREST: Surgery, stenting of carotid artery yielded similar safety, efficacy
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International Stroke Conference 2010
Carotid endarterectomy and carotid artery stenting demonstrated similar long-term safety and efficacy, but occurrences of MI, stroke and mortality differed according to age, study results presented at the International Stroke Conference in Houston indicated.
Researchers for the CREST trial enrolled symptomatic patients (n=1,321) who experienced either a nondisabling stroke or transient ischemic attack within the past six months or asymptomatic patients (n=1,181) who had not experienced either a stroke or transient ischemic attack within the same period. Among these patients, 2,502 were randomly assigned to either carotid endarterectomy or carotid artery stenting. The primary study endpoint was a composite of any stroke, MI or death within 30 days or ipsilateral stroke during follow-up.
The researchers reported that during the 30-day period following the procedures, stroke rate was 2.3% in patients undergoing surgery vs. 4.1% in patients undergoing stenting (HR=1.79; 95% CI, 1.14-2.82). Rates of MI were higher in patients undergoing surgery vs. those undergoing stenting (2.3% vs. 1.1%; HR=0.50; 95% CI, 0.26-0.94). Patients aged younger than 69 years tended to have better outcomes than older patients, including a larger stent benefit as the age of the patient decreased. In patients aged older than 70 years, results of endarterectomy were better than stenting results, with larger benefits for surgery as the age of the patient increased. Patients who had MI self-reported better quality of life after recovery than patients experiencing stroke.
“The findings that we have reported today apply to both symptomatic and asymptomatic patients, and importantly, when compared with previous trials, what we have reported today applies to both men and women,” Thomas Brott, MD,professor of neurology and director for research at the Mayo Clinic in Jacksonville, Fla., said in a press conference.
“We regret to say that despite our efforts, we did not have sufficient numbers of minorities enrolled that would help widen the application of the results, but the results presented regarding symptomatic and asymptomatic patients hold.” – by Eric Raible
This is very good news for patients. Perhaps the best news is that both of these therapies had incredibly low event rates that confirmed both their safety and effectiveness. This shows how far we have come in stroke therapies. It should not be lost on anybody that this is the largest and most rigorous trial to date of this therapy. So now patients not only have effective therapies, but they now have choices about what therapies are best for them individually. For this population of patients, they will now have both options available.
We will have to see how these results roll out and are adopted into clinical practice. There will be patients who prefer the less invasive therapy, and I am sure there will be patients who will prefer the surgical therapy. As this is approved by the FDA and is adopted by payers, it should have a great influence on practice. Both of these techniques have improved greatly over time.
– Kenneth Rosenfield, MD
Director, Cardiac
and Vascular Invasive Service
Massachusetts General Hospital, Boston
Member, Society of Cardiovascular Angiography and Interventions
This will change practice, because this is the first U.S.–based, large, multicenter, randomized trial. In the United States within the last 10 years, there have been multiple single-arm randomized registries in patients who are at high risk for surgery. This is the first U.S.–based trial that included patients who were not at high risk for surgery. In several European randomized trials of symptomatic patients, all of them had their problems in terms of the number of patients randomly assigned, the expertise of the specialists performing the stenting and others. This was a practice-changing trial that was well powered with the number of patients and the rigor in which it was conducted.
– Issam Moussa, MD
Director, Endovascular
Service
Weill Medical College, Cornell University, Ithaca, N.Y.
Member,
Society of Cardiovascular Angiography and Interventions
Brott T. #197. Presented at: International Stroke Conference; Feb. 24-26, 2010; San Antonio.
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