Endarterectomy vs stenting:
What have we learnt from CREST
study?
Vipul Gupta
Head,
Neurointervention
Medanta Institute of
Neurosciences
CREST: Study Design
Major eligibility criteria
Primary Endpoint
Periprocedural outcome- death, stroke,
MI
30-day endpoint components
Secondary Results – 2 year
Female sex ,
Diabetes , and dyslipidaemia
were independent predictors of
restenosis or occlusion after
the two procedures.
Restenosis or occlusion
Carotid artery stenting -
6%
Carotid endarterectomy -
6·3%
Smoking predicted an increased rate of restenosisafter carotid endarterectomybut not after carotid artery
stenting
Multi-centre randomized trials- the
controversy
Randomized controlled trials, the issue….
Management of MI as an
endpoint
Inclusion and ascertainment of
MI as a primary endpoint
Operator experience and
outcomes
Further analysis of CREST
Minor stroke worse than MI?
Neurological Residual Deficit Rates by NIHSS
Associated with Minor Strokes, Equal at 6 months
Long-term mortality after peri-procedural events:
No association with minor stroke, but strong
association of MI
Cranial nerve injury- not serious (not included
in primary end point) ?
No observed CAS-related
cranial nerve injury (CNI)
Less CAS access site complications
Death or Any Stroke Rates Decrease for CAS
over the Period of CREST Enrollment
Death or Major Stroke Rates in CAS
Decrease for Symptomatic Patients
Changes in Hazard Ratio by age group:
No age trend
Per protocol analysis
FDA Panel
•Circulatory Systems Devices panel of the
FDA on Jan 26, 2011
•Voted in favour of expanding use of
carotid stents to standard risk patients
Recommendations…
Guideline on the Management of Patients With
Extracranial Carotid and Vertebral Artery Disease
Published in journal- Stroke 2011
As accepted by: American Heart Association, American Stroke
Association, American Association of Neurological Surgeons, American
Society of Neuroradiology, Congress of Neurological Surgeons, Society
of NeuroInterventional Surgery, Society for Vascular Medicine, and
Society for Vascular Surgery
Recommendations for Carotid Revascularization
# Symptomatic patients- CEA if stenosis is more than 70%
(noninvasive imaging) or more than 50% by catheter angiography and
risk is less than 6% (Class I)
# CAS is indicated as an alternative to CEA for symptomatic patients
when the anticipated rate of periprocedural stroke or mortality is less
than 6% (Class I)
Latest guidiline – 2014 – less than 70 yrs, Cas may be preferable
Conclusions
CREST is the largest and most rigorous trial
Serious lacunae in European trials (training, MI,
credentialing, PD…)
CREST- CAS and CEA results are same
More minor strokes in CAS; more MI in CEA
Overall complication rates within acceptable limits,
serious stroke less than 1%
Long-term stroke rate/restenosis/occlusion – no
difference
Sub-analysis of CREST
Minor strokes recover
MI not benign
Cranial nerve injuries in CEA cannot not be
ignored
Stenting results kept improving during the trial
period- learning curve remains important
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