Analysis of CREST Compares Safety of CAS and CEA by Symptomatic Status

February 22, 2011—An analysis of data from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) to determine safety in symptomatic and asymptomatic patients was published in Stroke by Frank L. Silver, MD, et al for the CREST investigators (2011;42:675–680).

The investigators noted that CREST is a randomized trial comparing safety and efficacy of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in patients with high-grade carotid stenoses. Patients were defined as symptomatic if they had relevant symptoms within 180 days of randomization. The primary endpoint was stroke, myocardial infarction, or death within the periprocedural period or ipsilateral stroke up to 4 years.

As detailed in Stroke, for 1,321 symptomatic and 1,181 asymptomatic patients, the periprocedural aggregate of stroke, myocardial infarction, and death did not differ between CAS and CEA (5.2% versus 4.5%; hazard ratio [HR], 1.18; 95% confidence interval [CI], 0.82–1.68; P = .38). The stroke and death rate was higher for CAS versus CEA (4.4% versus 2.3%; HR, 1.9; 95% CI, 1.21–2.98; P = .005). For symptomatic patients, the periprocedural stroke and death rates were 6%±0.9% for CAS and 3.2%±0.7% for CEA (HR, 1.89; 95% CI, 1.11–3.21; P = .02). For asymptomatic patients, the stroke and death rates were 2.5%±0.6% for CAS and 1.4%±0.5% for CEA (HR, 1.88; 95% CI, 0.79–4.42; P = .15). Rates were lower for those aged < 80 years.

The investigators concluded that there were no significant differences between CAS versus CEA by symptomatic status for the primary CREST endpoint. Periprocedural stroke and death rates were significantly lower for CEA in symptomatic patients. However, for both CAS and CEA, stroke and death rates were below or comparable to those of previous randomized trials and were within the complication thresholds suggested in current guidelines for both symptomatic and asymptomatic patients.