CHICAGO–The recent Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) that compared carotid artery stenting (CAS) and carotid endarterectomy (CEA) found no difference in patient outcomes between the two procedures; however vascular surgeons’ cases had better rates for lower strokes for CEA and lower myocardial infarction (MI) for CAS. These results are detailed in the January issue of the Journal of Vascular Surgery®.
“Rigorous credentialing and training of interventionists, including vascular surgeons, were required for this randomization controlled phase of CREST,” said co-author Thomas G. Brott, MD, professor of neurology and director for research at the Mayo Clinic in Jacksonville, Fla. “Previously the lead-in phase of CREST had suggested higher perioperative risks after CAS performed by vascular surgeons; our analysis examined differences in outcomes after randomization between CAS and CEA performed by them.”
“There were remarkably low stroke and death rates after CEA performed by vascular surgeons in CREST, particularly among symptomatic patients,” said Dr. Brott. “These data represent the best outcomes ever reported after carotid interventions from a randomized controlled trial and suggest that appropriately trained vascular surgeons may safely offer both CEA and CAS for the prevention of stroke.”
Vascular surgeons performed 237 (21 percent) of the CAS procedures and 765 (65 percent) of the CEA procedures among 2,320 patients who received their randomized assigned treatment. The composite primary end endpoint was comprised of stroke, MI, or death during the periprocedural period or ipsilateral stroke within four years. Proportional hazards analyses were used to estimate the relative efficacy of CAS vs. CEA for the composite primary end point, and for stroke and death.
For procedures performed exclusively by vascular surgeons, the primary end point did not differ between CAS and CEA at 4-year follow-up (6.2 percent vs. 5.6 percent, respectively; hazard ratio [HR], 1.30; 95 percent confidence interval, 0.70-2.41; P =.41). In this subgroup, the periprocedural stroke and death rates were higher after CAS than CEA for symptomatic patients (6.1 percent vs. 1.3 percent; P=.01).
Asymptomatic patients had slightly higher stroke and death rates after CAS (2.6 percent vs. 1.1 percent; P=.20), although this difference did not reach statistical significance. Conversely, cranial nerve injuries (0.0 percent vs. 5.0 percent; P < .001) were less frequent after CAS than CEA.
The MI rates were slightly lower after CAS (1.3 percent vs. 2.6 percent; P=.24). In performing CAS, vascular surgeons had outcomes for the periprocedural primary end point comparable to the outcomes of all interventionists (HR, 0.99; 95 percent confidence interval, 0.50-2.00) after adjusting for age, sex, and symptomatic status. Vascular surgeons also had similar results after CEA for the periprocedural primary end point compared with other surgeons (HR, 0.73; 85 percent, 0.42-1.27).
About Journal of Vascular Surgery®
Journal of Vascular Surgery
® provides vascular, cardiothoracic and general surgeons with the most recent information in vascular surgery. Original, peer-reviewed articles cover clinical and experimental studies, noninvasive diagnostic techniques, processes and vascular substitutes, microvascular surgical techniques, angiography and endovascular management. Special issues publish papers presented at the annual meeting of the Journal's sponsoring society, the Society for Vascular Surgery®. Visit the Journal
Web site at www.jvascsurg.org/
About the Society for Vascular Surgery
The Society for Vascular Surgery® (SVS) is a not-for-profit professional medical society, composed primarily of vascular surgeons, that seeks to advance excellence and innovation in vascular health through education, advocacy, research, and public awareness. SVS is the national advocate for 4,008 specialty-trained vascular surgeons and other medical professionals who are dedicated to the prevention and cure of vascular disease. Visit its Web site at www.VascularWeb.org®