Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST), a federally funded study was conducted to compare the results of traditional heart surgery vs. a new, less invasive procedure called stenting to eradicate plaques in clogged neck arteries, also called carotid arteries. Study findings revealed that carotid artery stenting would be as safe and effective as carotid surgery in patients at risk for stroke.
The trial was conducted for a period of 9 years and focused on a group of 2,502 patients who all either had a stent implanted into them, or a traditional heart surgery known as an endarterectomy.
Earlier, stent placement was restricted only to patients with previous stroke symptoms and who are at high surgical risk. The current trial findings have now fuelled doctors and manufacturers to push for making Medicare reimbursements available to a larger population to undergo this procedure. About 30,000 carotid-stent placements occur in the U.S. annually, compared with more than 100,000 carotid operations.
Strokes occur when the flow of blood to the brain is obstructed due to clogged carotid arteries. Patients in CREST were observed for an average of 2.5 years, with some patients followed up to four years. The rate of short-term adverse events—stroke, heart attack or death—plus longer-term stroke was statistically the same in the stent patients (7.2%) as in the surgery patients (6.8%).
In the 30 days following the procedure, the heart-attack rate was higher in the surgical patients (2.3%) than in stented patients (1.1%). Conversely, the 30-day rate of stroke was higher in the stenting group, at 4.1%, than in the surgery patients, 2.3%. Dr. Thomas G. Brott, the lead investigator of the CREST study said, “patients’ quality of life was impacted more by the strokes than by the heart attacks” one year after suffering those events. Still, the rates of complications were low, compared with those of similar studies in recent years.
The Crest trial, sponsored by the National Institute of Neurological Disorders and Stroke with additional financing from the stent maker Abbott Vascular, is one of the largest randomized clinical trials to study the two major procedures used to open blocked neck arteries and restore blood flow to the brain.
Another study published in Lancet, the International Carotid Stenting Study, disagreed with the conclusions of CREST trial and said there are three other trials that suggest surgery is safer than stenting. However, a plausible explanation for this disparity is that the European study included only symptomatic patients, who may have had more advanced disease, whereas the North American trial carefully screened the doctors doing the stenting procedure, including only highly skilled physicians with a lot of experience.
Written by Snigdha Taduri