CREST Results Published in NEJM Show Equivalence of CAS to CEA
May 26, 2010—The CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) study results were published by Thomas G. Brott, MD, et al online ahead of print in the New England Journal of Medicine. The data were presented for the first time on February 26 at the International Stroke Conference 2010 in San Antonio, Texas and were reported at that time by Endovascular Today.
As detailed in the New England Journal of Medicine, the CREST study randomly assigned patients with symptomatic or asymptomatic carotid stenosis to undergo carotid artery stenting (CAS) or carotid endarterectomy (CEA). The primary composite endpoint was stroke, myocardial infarction (MI), or death from any cause during the periprocedural period or any ipsilateral stroke within 4 years after randomization.
The CREST investigators concluded, “Among patients with symptomatic or asymptomatic carotid stenosis, the risk of the composite primary outcome of stroke, MI, or death did not differ significantly in the group undergoing CAS and the group undergoing CEA. During the periprocedural period, there was a higher risk of stroke with stenting and a higher risk of MI with endarterectomy.”
The investigators reported that for 2,502 patients over a median follow-up period of 2.5 years, there was no significant difference in the estimated 4-year rates of the primary composite endpoint between the CAS group and the CEA group (7.2% vs 6.8%; hazard ratio with stenting, 1.11; 95% confidence interval, 0.81–1.51; P = .51). There was no differential treatment effect with regard to the primary endpoint according to symptomatic status (P = .84) or sex (P = .34).
For CAS and CEA, the 4-year rate of stroke or death was 6.4% and 4.7% (hazard ratio, 1.5; P = .03), the rates among symptomatic patients were 8% and 6.4% (hazard ratio, 1.37; P = .14), and the rates among asymptomatic patients were 4.5% and 2.7% (hazard ratio, 1.86; P = .07), respectively. Periprocedural rates of individual components of the endpoints differed between the CAS group and the CEA group for death (0.7% vs 0.3%; P = .18), stroke (4.1% vs 2.3%; P = .01), and MI (1.1% vs 2.3%; P = .03). After this period, the incidences of ipsilateral stroke with CAS and with CEA were similarly low (2% vs 2.4%; P = .85).
In an accompanying editorial published online ahead of print in the New England Journal of Medicine, Stephen M. Davis, MD, and Geoffrey A. Donnan, MD, concluded that given the lack of significant difference in the rate of long-term outcomes, the individualization of treatment choices is appropriate. They advised that more long-term data are needed before a full appreciation of the relative risks and benefits of CAS and CEA can be made.
According to Drs. Davis and Donnan, until more data are available, CEA remains the preferred treatment for most patients with symptomatic carotid stenosis and that treatment for asymptomatic stenosis remains controversial. They added that though it appears that the increased risk of stroke with CAS is offset by an increased risk of MI with CEA, stroke has greater long-term health consequences than MI. The risk-benefit issue is complex and should be discussed with patients.