Surgery and Stenting Found to be Equally Safe and Effective for Stroke Prevention in Patients with Carotid Artery Disease
Results from a large-scale study of people at risk for stroke showed that two medical procedures designed to prevent future strokes in patients with carotid artery disease are safe and effective overall. Physicians will now have more options in tailoring treatments for their patients at risk for stroke. The multi-center trial of 2,502 participants compared carotid endarterectomy (CEA), a surgical procedure to clear blocked blood flow and considered the gold standard prevention treatment, to carotid artery stenting (CAS), a newer and less invasive procedure that involves threading a stent and expanding a small protective device in the artery to widen the blocked area and capture any dislodged plaque.
One of the largest randomized stroke prevention trials ever, the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST), took place at 117 centers in the United States and Canada over a nine-year period. CREST examined the safety and effectiveness of CEA and CAS in patients with or without a previous stroke. The trial was funded by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health, and led by investigators at Mayo Clinic, Jacksonville, Fla., and the University of Medicine and Dentistry of New Jersey in Newark. Northwestern Memorial Hospital was among the participating centers.
The overall safety and efficacy of the two procedures was largely the same with equal benefits for both men and for women, and for patients who had previously had a stroke and for those who had not. However, when the investigators looked at the numbers of heart attacks and strokes that occurred after the procedure, they found differences. The investigators found that there were more heart attacks in the surgical group, 2.3 percent compared to 1.1 percent in the stenting group; and more strokes in the stenting group, 4.1 percent versus 2.3 percent for the surgical group in the weeks following the procedure.
The study also found that the age of the patient made a difference. At approximately age 69 and younger, stenting results were slightly better, with a larger benefit for stenting, the younger the age of the patient. Conversely, for patients older than 70, surgical results were slightly superior to stenting, with larger benefits for surgery, the older the age of the patient.
“Carotid artery occlusive disease is responsible for a large number of strokes that occur every year in this country. While medical therapy remains the cornerstone for stroke prevention, patients with severe narrowing of their carotid artery require something more,” said Mark K. Eskandari, M.D., vascular/endovascular surgeon, director of carotid and peripheral artery interventions at Northwestern Memorial’s Bluhm Cardiovascular Institute and principal investigator for the trial. “Having more than one reliable treatment option will allow us to personalize care and will play an important role in improving patient outcomes. Our group of vascular surgeons has had a long track record of stellar outcomes with both carotid surgery and stenting.”
Stroke is the third leading cause of death in the United States and is caused by an interruption in blood flow to the brain by a clot or bleeding. The carotid arteries on each side of the neck are the major source of blood flow to the brain. Buildup of cholesterol in the wall of the carotid artery, called atherosclerotic plaque, is a major risk factor for the most common type of stroke, known as ischemic stroke. Because people with carotid atherosclerosis also usually have atherosclerosis in the coronary arteries that supply the heart, the CREST trial tracked the rate of heart attacks following the procedure, in addition to stroke and death.
The researchers point out that the rate of stroke and death in the surgical group was the lowest ever reported in a large stroke prevention trial. As a result, the pivotal differences were the lower rate of stroke following surgery and the lower rate of heart attack following stenting, according to the investigators. A year after the procedure, the patients who had suffered a stroke reported that the effects of the stroke had a greater impact on their quality of life than was reported by those patients who had suffered a heart attack.
Overall, the CREST investigators concluded that while CEA has a proven record and long term durability, both CAS and CEA are safe and useful tools in the right setting for stroke prevention, and technology continues to improve each procedure.
Partial funding for the study was supplied by Abbott, of Abbott Park, Ill., the maker of the stents.
Jennifer Monasteri, Manager