MedWire News: CREST finds similar long-term outcomes among patients allocated to carotid artery stenting (CAS) or carotid endarterectomy (CEA), as reported in the New England Journal of Medicine.
More patients in the stenting group suffered stroke during the periprocedural period between randomization and 30 days after intervention, whereas more in the surgery arm had a myocardial infarction. But stroke had a larger long-term impact on health.
“The risk–benefit issue is complex and should be discussed with patients,” said the authors of an accompanying editorial, Stephen Davis and Geoffrey Donnan (University of Melbourne, Australia).
The CREST (Carotid Revascularization Endarterectomy vs Stenting Trial) investigators randomly assigned 2502 patients with symptomatic or asymptomatic (≥60% stenosis on angiography) carotid stenosis to undergo CAS or CEA.
As previously reported, CAS operators were required to complete 50 procedures in a run-in phase, before being included in the trial proper.
Patients were followed-up for up to 4 years (median 2.5 years), during which time 7.2% of the CAS group and 6.8% of the CEA group met the primary endpoint of periprocedural stroke, myocardial infarction, or all-cause death; or stroke during long-term follow-up. The difference was not statistically significant.
Stroke or death rates at the end of follow-up among symptomatic patients were 8.0% with CAS versus 6.4% with CEA. The corresponding rates among asymptomatic patients were lower overall, at 4.5% versus 2.7%.
The differences between treatment groups were driven by a significantly higher rate of periprocedural stroke in the CAS group overall, at 4.1% versus 2.3% in the CEA group. Conversely, myocardial infarction was less common, at 1.1% versus 2.3%.
However, major and minor stroke had a significant impact on health 1 year later, resulting in respective 15.8- and 4.5-point reductions in the physical component scale of the Short Form (SF)-36, relative to no stroke. By contrast, myocardial infarction was associated with a nonsignificant 3.0-point reduction versus no myocardial infarction.
After the periprocedural period, stroke rates were similar, at 2.0% for CAS and 2.4% for CEA.
Thomas Brott (Mayo Clinic, Jacksonville, Florida, USA) and colleagues conclude: “The low absolute risk of recurrent stroke suggests that both CAS and CEA are clinically durable and may also reflect advances in medical therapy.”
In their editorial, Davis and Donnan described the event rates in CREST as “impressively low,” but said that “the results are broadly consistent with those in previous trials.”
They said that “until more data are available, carotid endarterectomy remains the preferred treatment for most patients with symptomatic carotid stenosis.”
But they concluded: “Given the lack of significant difference in the rate of long-term outcomes, the individualization of treatment choices is appropriate.”
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