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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003ECarotid endarterectomy (CEA) and carotid artery stenting (CAS) are viable options for revascularization, and these strategies are comparable with regard to safety and efficacy for the prevention of ischemic strokes. However, the favorability of CEA and CAS varies according to individual risk factors. This article discusses results from the Carotid Revascularization Endarterectomy versus Stenting [CREST] Trial.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eneurology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecerebrovascular disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eischemia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eneurology clinical trials\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EDetails from the CREST Study\u003C\/h2\u003E\u003Cp id=\u0022p-2\u0022\u003ECarotid endarterectomy (CEA) and carotid artery stenting (CAS) are viable options for revascularization, and these strategies are comparable with regard to safety and efficacy for the prevention of ischemic strokes. However, the favorability of CEA and CAS varies according to individual risk factors. Wayne M. Clark, MD, Oregon Health Sciences University, Portland, OR, presented results from the long-awaited Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ECREST was a prospective, multicenter (108 US and 9 Canadian sites), randomized, controlled trial with blinded endpoint adjudication that compared CEA (n=1240) and CAS (n=1262) in patients with symptomatic and asymptomatic stenosis. The primary endpoints were the periprocedural composite of any clinical stroke, myocardial infarction (MI; defined as elevation of cardiac enzymes 2+ times the upper limit of normal plus chest pain or ECG changes with definitive ST changes), and death and postprocedural ipsilateral stroke in the treated vessel for up to 4 years. Secondary endpoints were differential efficacy by symptomatic status, gender and age, differential restenosis, and quality of life and cost effectiveness [CREST. \u003Cem\u003EInt J Stroke\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EStroke was defined as an acute neurological ischemic event of \u226524 hours in duration with focal signs and symptoms that were adjudicated by at least 2 neurologists who were blinded to treatment. Symptomatic and asymptomatic carotid stenosis was determined by angiography, ultrasonography, or CTA\/MRA. Patients with chronic atrial fibrillation, evolving stroke or major stroke that was likely to confound study endpoints, MI within 30 days, unstable angina, or enzyme-only MI were excluded from study participation. Baseline characteristics were well matched. Most participants had a high degree of stenosis (\u0026gt;70% stenosis in 85% of CAS patients and 87% of CEA patients), and procedures were performed an average of 20 to 25 days after the qualifying event in symptomatic patients.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003ENo significant differences were found in the primary endpoints, and no differences between the two procedures were observed that were related to symptomatic status or gender. However, CAS was superior to CEA in patients aged \u226470 years, while more favorable outcomes were noted with CEA in patients aged \u0026gt;70 years (p interaction=0.020). Overall, there was no difference in outcome when looking at the periprocedural composite of all stroke and MI, but when considering these risks individually, the differences were statistically significant. CEA was associated with lower rates of all stroke (HR, 1.79; 95% CI, 1.14 to 2.82; p=0.01), and CAS was associated with lower rates of MI (HR, 0.50; 95% CI, 0.26 to 0.94; p=0.03; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Periprocedural cranial nerve palsies were more frequent in patients who received CEA than CAS (p\u0026lt;0.0001). Quality of life and cost effectiveness data from CREST are pending.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/11\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022CEA\/CAS Comparison.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1966055423\u0022 data-figure-caption=\u0022CEA\/CAS Comparison.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/11\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/11\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/1\/11\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11191\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003ECEA\/CAS Comparison.\u003C\/p\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from W. Clark, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003E\u201cAt experienced centers, both CEA and CAS appear to have low perioperative complications and excellent long-term results. I feel that we now have two options we can offer to our patients to prevent carotid artery strokes,\u201d Dr. Clark said.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EThomas G. Brott, MD, Mayo Clinic, Jacksonville, FL, an investigator in the CREST trial, elaborated on these findings. The average life expectancy has also increased in recent years. Therefore, the age-related data that were gleaned from CREST are quite important. Dr. Brott pointed out that comparing CEA and CAS in both asymptomatic and symptomatic stenosis was a key feature of CREST, as it allowed the results to be applied to a more general population. Previous studies have focused on more specific symptom-driven cohorts. CTA and MRA were added during the latter part of the study to ensure that the documented stenosis was genuine. CREST attempted to accommodate changes in technology as the study progressed (eg, the addition of CTA\/MRA).\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThe procedures seem to be clinically durable. \u201cOne explanation for this durability may be that modern medical therapy may have progressed to the point where perhaps the procedure did not necessarily have to be done,\u201d said Dr. Brott. Medical therapy has advanced dramatically over the past decade, and the possibility that successful outcomes are owing more to better medications than to the procedures themselves merits further investigation.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EHow does CREST Compare with Other Trials?\u003C\/h2\u003E\u003Cp id=\u0022p-10\u0022\u003EMartin Brown, MD, University College, London, UK, discussed some other randomized controlled trials (RCTs) in relation to CREST and CEA versus CAS. \u201cRCTs provide the best data to assess the effects of treatment and, more importantly, assure that patients are well matched. However, an RCT is only as good as its sample size,\u201d said Dr. Brown. While CREST results correspond with previous CEA and CAS study findings, there is a huge disparity between sample sizes for these studies.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EIn the SPACE study, 30-day safety data favored CEA over CAS (rate of stroke or death 6.5% for CEA vs 7.7% for CAS). However, this study was not very large and was discontinued due to futility and funding issues. There were several crucial differences in SPACE compared with CREST. For example, MI was not included as an outcome event, and there were a variety of stents and devices that were approved in SPACE. The rate of ipsilateral stroke or death was identical for CEA and CAS (5.9%) in patients aged younger than 76 years in SPACE but favored CEA (7.5% vs 11.1% for CAS) in patients aged older than 76 years [The SPACE Collaborative Group. \u003Cem\u003ELancet\u003C\/em\u003E 2006].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EThe EVA-3S study demonstrated results that were similar to those found in the CREST study. EVA-3S was discontinued early (after randomization of 527 patients) due to significantly better 30-day outcomes for CEA compared with CAS. The rate of stroke or death was significantly lower for CEA compared with stenting (3.9% vs 9.6% for CAS; p=0.01) [Mas JL et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2006].\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EThe International Carotid Stenting Study (ICSS) was similar to CREST by design, and it was thought that the results would correlate. One major difference in ICSS is that it included only patients with recently symptomatic carotid stenosis. The use of protective devices and the type of stent were left to the interventionalists\u0027 discretion, as was the use of aspirin and clopidogrel prior to stenting. At 120 days, the primary short-term outcome (stroke, death, or periprocedure MI) favored CEA (p=0.006). Thirty-day rates of stroke or death were higher in the CAS group compared with CEA (p\u0026lt;0.001) [International Carotid Stenting Study Investigators. \u003Cem\u003ELancet\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EIn a substudy of ICSS that focused on MRI detection of new ischemia, the rates of new ischemia in the CEA group were lower than in the CAS group (OR 5.21; 95% CI, 2.78 to 9.79; p\u0026lt;0.0001) [Bonati et al. \u003Cem\u003ELancet Neurol\u003C\/em\u003E 2010]. Silent infarcts were more frequent after CAS, regardless of age, and were more common when protection devices were utilized.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EA subgroup analysis of pooled data from EVA-3S, SPACE, and ICSS is currently underway. Preliminary data have demonstrated favorable outcomes within 30 days of treatment for CEA versus CAS, particularly in regard to the risk of any stroke or death (p\u0026lt;0.0001) [data not yet published]. However, more data are needed to determine the long-term efficacy of CEA and CAS, and it is not yet known if the benefit is equivalent.\u003C\/p\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\u003Ch2 class=\u0022\u0022\u003EWho Benefits from Treatment?\u003C\/h2\u003E\u003Cp id=\u0022p-16\u0022\u003EPeter Rothwell, MD, University of Oxford, Oxford, UK, showed that neither treatment is merited in many patients, and these interventions should only be used in those patients with severe symptomatic stenosis. Although some of the excess stroke risk that is associated with CAS versus CEA is due to minor stroke, these events should be taken very seriously, because it is a reduction in minor stroke that accounts for most of the benefit of these interventions compared with medical treatment alone in the first place, said Dr. Rothwell. In symptomatic patients, the procedural risk of stroke with CAS in CREST was double that of CEA (6% vs 3%), which is consistent with previous studies. Based on these findings, CAS may be no better than medical treatment alone in moderately symptomatic patients. The similar relative excess risk of stroke with CAS versus CEA in patients with asymptomatic stenosis will also result in better outcomes on intensive medical treatment alone in this group [Rothwell PM. \u003Cem\u003ELancet\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003ETherefore, who will benefit most from CEA or CAS? The answer to that question is not as straightforward as one would hope. Men have shown a greater benefit from CEA than women [Rothwell PM et al. \u003Cem\u003ELancet\u003C\/em\u003E 2004]. However, benefit and risk increase with age independently of gender [Rothwell PM et al. \u003Cem\u003ELancet\u003C\/em\u003E 2005]. The increased procedural risk of stroke with CAS versus CEA in patients aged over 65\u201370 years appears to be consistent across multiple studies and may be due to the increase in calcification of vessels and plaques with age [Redgrave J et al. \u003Cem\u003EStroke\u003C\/em\u003E 2010. In press]. These and other risk factors should be weighed carefully before deciding on a treatment strategy.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EResults from the CREST study have elucidated the benefit and risk of CEA versus CAS, particularly in relation to individual outcomes, such as MI and stroke. While the risk of stenting may have been expected to decrease over time in light of technological advances and more procedural experience, this has yet to be shown to be the case. More data are needed to assess the long-term risks of CAS. Given the current evidence of a greater procedural risk of stroke, greater asymptomatic infarction, and greater restenosis with CAS versus CEA, CEA must remain the treatment of choice in routine clinical practice.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2010 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/10\/1\/11.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmtwq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmtwq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}