CAS and CEA Show Equal Safety and Efficacy at Lowering Long-Term Stroke Risk in 10-Year CREST Results
March 21, 2016—The Mayo Clinic in Jacksonville, Florida, recently announced that the 10-year findings from the CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) study demonstrated that stenting and surgery are equally effective at lowering the long-term risk of stroke from a narrowed carotid artery. The 10-year CREST results were presented at the American Heart Association’s 2016 International Stroke Conference, held February 17–19 in Los Angeles, California, and published by Principal Investigator Thomas G. Brott, MD, et al for the CREST investigators in The New England Journal of Medicine (2016;374:1021–1031). Dr. Brott is a neurologist and the Eugene and Marcia Applebaum Professor of Neurosciences at Mayo Clinic’s campus in Florida.
According to the Mayo Clinic, CREST is one of the largest randomized stroke prevention trials ever conducted. The study enrolled 2,502 patients (average age, 69 years) at 117 centers in the United States and Canada and followed for up to 10 years. The centers were coordinated through Rutgers-New Jersey Medical School in Newark, New Jersey, and the patient results were analyzed at the University of Alabama at Birmingham in Birmingham, Alabama.
The study found the risk for stroke after either carotid artery stenting or carotid endarterectomy was approximately 7% and the rate of restenosis was low for both stenting and surgery at approximately 1% per year. Equal benefit was found for older and younger individuals, men and women, patients who had previously had a stroke, and those who had not.
In the Mayo Clinic press release, Dr. Brott commented, “This very low rate shows these two procedures are safe and are also very durable in preventing stroke. Because Medicare-age patients with carotid narrowing are living longer, the durability of stenting and surgery will be reassuring to the patients and their families.”
The Mayo Clinic noted that in 2010 results from phase one of CREST demonstrated that stenting and surgery were equally safe procedures, with fewer strokes among those who had surgery, and fewer heart attacks among those who received stents. Those results were presented at the 2010 International Stroke Conference and published by Dr. Brott et al in The New England Journal of Medicine (2010;363:11–23).
Dr. Brott stated, “This second phase completes a story, and the results are very encouraging. We have two safe procedures. We know now that they are very effective in the long run. Now the patient and the physician have the option to select surgery or stenting, based on that individual patient’s medical condition and preferences.”
Walter Koroshetz, MD, Director of the National Institute of Neurological Disorders and Stroke, added, “The stroke rate in CREST was less than half of what was seen in similar studies from the late 1900s, which reinforces the benefits of modern medical control of vascular risk factors.”
The Mayo Clinic noted that despite the results of CREST, the question of the best way to manage stroke risk has not been answered yet. Because of that, CREST-2 was launched in December 2014 to compare stenting and surgery to medical management. CREST-2, which is expected to end in 2022, is being funded by a $39.5 million grant from the National Institute of Neurological Disorders and Stroke.
“Carotid narrowing causes about 5% to 10% of all strokes in the United States. [Because] there are about 800,000 strokes a year, we’re talking about 40,000 to 50,000 strokes a year. If we can find the best way to prevent those strokes, then we will have provided a service to those patients,” concluded Dr. Brott in the Mayo Clinic announcement.