CREST Data: Stroke Risk With Multiple Carotid Stents

BY MARK S. LESNEY

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The procedural risk of carotid artery stenting is significantly increased with increasing number of stents used, according to an analysis of the Carotid Revascularization Endarterectomy vs. Stenting Trial lead-in data, said Dr. Robert W. Hobson II.

The lead-in phase of CREST includes data on carotid artery stenting (CAS) procedures performed on symptomatic patients with greater than or equal to 50% carotid artery stenosis, and asymptomatic patients with greater than or equal to 70% stenosis.

Data from the start of the registry in 2000 to 2006 were reviewed to assess the impact of number of stents used in CAS on 30-day stroke rates by Dr. Hobson and his colleagues from the New Jersey Medical School, Newark, and other centers. Their research was presented at the Vascular Annual Meeting

The CREST registry included 1303 patients, 347 symptomatic and 956 (nearly 74%) asymptomatic. The mean age of the patients was approximately 70 years of age, nearly 37% were women, and the mean stenosis treated was 85.7%, according to Dr. Hobson.

Other important demographics included a history of diabetes (32.7%), coronary artery bypass grafting (24.4%), dyslipidemia (89.3%), current smoking (18.1%), and hypertension (84.4%), he said in an interview, but for the purposes of this study, patients with one versus two or three stents implanted had no significant demographic differences.

The majority of patients treated were less than 80 years of age (nearly 89%), and the majority of lesions treated had mean diameter stenosis less than or equal to 80% (nearly 56%), he added.

In total numbers, strokes were observed in 55 (4.2%) of the 1303 CAS procedures reported. This comprised 46/55 strokes in patients who received one stent, 9/55 who received two (8 patients) or three (1 patient) stents. This translated to a 30-day stroke rate with one stent of 4.0% and with two or three stents of 13.2%, a highly significat difference at P = 0.0002.

Previous researchers have demonstrated an increased stroke risk associated with carotid stenting from factors such as patient age, history of diabetes, anatomic anomalies such as a type III aortic arch, primary atherosclerotic lesions, arterial tortuosity, and stenosis greater than or equal to 90%, he said.

The influence of technical aspects on periprocedural aspects has not been well defined. "Our results confirm that a significant relationship exists between the number of stents used and the procedural risk of CAS," he stated, "and emphasize the importance of making every effort to utilize a single stent to cover the carotid lesion in CAS procedures."

When asked to comment on this article, Dr. Ali AbuRahma, professor of Surgery and chief of vascular and endovascular surgery, and medical director of the vascular laboratory at Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, stated: "The data from the study comes from a well-respected institution that has been advocating active participation in randomized carotid stent trials, with Dr. Hobson being the principal investigator of the CREST trial. As noted in their conclusion, the stroke rates were impressively different when more than one stent was inserted, specifically 4% for one stent versus 13.2% for more than one stent. It is also noticeable in this series that 74% of the enrolled patients had asymptomatic disease. "These findings will only strengthen the recommendation that, presently, carotid stenting must be done as part of a randomized trial or as a part of protocol of clinical carotid trials until further conclusions are obtained, and hopefully the final CREST results will give us a conclusion for the role of carotid stenting, whether for symptomatic or asymptomatic good risk patients," concluded Dr. AbuRahma, who is also an editorial advisor for Vascular Specialist.

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