The CREST trial: Stenting versus endarterectomy for carotid stenosis [Classics Series]

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1. The rate of stroke, myocardial infarction or death did not differ significantly between patients treated with carotid artery stenting compared to carotid endarterectomy.

2. The periprocedural rate of stroke was higher with stenting while the rate of myocardial infarction was higher with endarterectomy.

Original Date of Publication: July 1, 2010

Study Rundown: Carotid artery stenosis occurs as a result of atherosclerosis and leads to increasing risk of embolus and stroke. Endarterectomy and stenting are two procedures used to treat carotid artery stenosis but the evidence regarding their comparative efficacies is indecisive. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) is one of the largest randomized controlled trials comparing these two treatment modalities. Prior to publication of these results, several trials had found higher rates of stroke and death associated with carotid artery stenting leading to a trend towards endarterectomy. The CREST trial found no significant difference in a composite outcome of stroke, myocardial infarction, and death between the two treatment groups (hazard ratio 1.11; 95%CI 0.81-1.51) and achieved lower rates of complications in both groups than those observed in previous trials. This supported both procedures as safe and effective treatment options; however, these results have been attributed to the highly trained interventionists involved in the study, which limits the external validity of the results. An interesting finding of the trial was that the rate of periprocedural stroke was higher in the stenting group while the rate of myocardial infarction was higher in the endarterectomy group. This has led to debate regarding the relative harmful effects of suffering a stroke compared to myocardial infarction with some agreement that stroke results in more debilitating long-term consequences.

In summary, the results of the CREST trial did not identify a definitive superior treatment for carotid artery stenosis. Treatment decisions should be individualized to patients characteristics and needs.

Please click to read study in NEJM

In Depth [randomized, controlled study]: Published in NEJM in 2010, this randomized, controlled trial enrolled 2,522 patients with symptomatic or asymptomatic carotid stenosis and randomized participants to receive carotid-artery stenting (CAS) or carotid endarterectomy (CEA). The primary outcome was a composite of stroke, myocardial infarction, and death during the periprocedural period, or ipsilateral stroke within four years of randomization. There was no significant difference in the 4-year rates of the primary endpoint between CAS and CEA for the sample as a whole, nor among symptomatic or asymptomatic patients separately. The rate of the primary endpoint during the periprocedural period did not differ between treatment groups; however, when components were analysed separately, the rate of stroke was higher with CAS while the rate of myocardial infarction was higher with CEA. Treatment effect was not modified by symptomatic status or sex; however, an interaction was detected between age and treatment efficacy, with CAS more effective in younger patients and CEA more effective in older patients.

By Adrienne Cheung, Andrew Cheung, M.D.

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