Stenting versus Endarterectomy for Treatment of

Carotid-Artery Stenosis (CREST Trial)

RFS Journal Primer

Quick Summary
BOTTOM LINE

In patients with symptomatic or asymptomatic carotid stenosis, no significant difference exists

between carotid artery stenting (CAS) and carotid endarterectomy (CEA) at four years for the
composite outcome of myocardial infarction, stroke and death.

MAJOR POINTS

For the composite four year outcome of myocardial infarction, stroke and death, no significant
difference is present between CAS and CEA among both symptomatic and asymptomatic patients.

Peri-procedurally, CAS was associated with a higher risk of stroke, while CEA has a higher risk of
myocardial infarction

Older patients (age>70) had a reduced incidence of the primary outcome with CEA compared to CAS,
while younger patients (age<70) had a reduced incidence of the primary outcome with CAS.

CRITICISM

Generalizability of results on a large scale is questionable. All interventionalists underwent rigorous

certification that may not be feasible in community practice.

Despite several systems being available, only one stenting system was used further limiting
generalizability of results to other stenting systems.

Only compares stenting vs endarterectomy, with no medical therapy arm. For asymptomatic
patients, it is unknown if either therapy is superior to medical therapy alone.

Unknown durability of stents during longer term follow-up (ie greater than four years).

Study design
Randomized, controlled trial with blinded end-point adjudication

2522 patients randomized (1251 endarterectomy, 1271 stenting)

Time range: 2000-2008

INCLUSION CRITERIA

Symptomatic carotid artery stenosis with imaging findings of stenosis >50% on

angiography, or >70% on ultrasound/CTA/MRA

Asymptomatic carotid artery stenosis with imaging findings of stenosis >60% on

angiography or greater than 70% on ultrasound or greater than 80% on
CTA/MRA

EXCLUSION CRITERIA

Severe prior stroke

Chronic atrial fibrillation

Paroxysmal atrial fibrillation in the past 6 months or requiring anticoagulation

Myocardial infarction in the past 30 days

Unstable angina

Study design

Figure 1. Study
design and
follow-up

Purpose

To compare outcomes of carotid artery stenting versus carotid endarterectomy in patients

with symptomatic or asymptomatic carotid stenosis.

Intervention

All interventionalists and surgeons included in the study were certified via a validated
selection process that included a clinical result audit.

Carotid artery stenting was performed using the RX Acculink stent and, if possible, with the RX
Accurnet embolic protection device.

For at least 48 hours prior to stenting, all patients received aspirin 325 mg BID and clopidogrel
75 mg BID. After the procedure, all patients received aspirin 325 (either daily or BID) as well
as either clopidogrel (75 mg daily) or ticlopidine (250 mg BID) for 1 month. Recommendations
were made to continue antiplatelet therapy beyond 1 month where possible.

At least 48 hours prior to carotid endarterectomy, all patients received aspirin 325 mg daily
and continued that dosage for at least 1 year. Alternatively, patients could have taken
ticlopidine 250 mg daily, clopidogrel 75 mg daily, aspirin 81 mg daily, or aspirin and
dipyradimole BID.

All patients underwent current guideline-based cardiovascular risk modification.

Outcome

Figure 3. Outcomes according to treatment group assignment and time frame of follow-up.

Outcome

Figure 4. Hazard ratio for primary outcome according to age for each treatment arm.
CAS-carotid artery stenting, CEA-carotid endarterectomy

Outcome

Primary endpoint was defined as the composite outcome of myocardial infarction, stroke, and
death during the peri-procedural period (defined as within 30 days post-procedure) as well as
ipsilateral stroke within 4 years of follow-up.

Overall, no significant difference was identified between the two groups for the primary
endpoint (CAS 7.2% vs CEA 6.8%, p=0.51).

In the peri-procedural period, CAS was associated with a higher risk of stroke (4.1% vs 2.3%,
p=0.01), while a higher risk of myocardial infarction was noted with CEA (1.1% vs 2.3%,
p=0.03).

Following the peri-procedural period, no significant difference was noted in the incidence of
ipsilateral stroke between the two groups (CAS 2.0%, CEA 2.4% p=0.85).

Patient under the age of 70 had a reduced risk of primary endpoint with CAS. Patient greater
than age 70 had a reduced risk of primary endpoint with CEA.

Credits

SUMMARY BY:

Sean A. Kennedy MD, PGY1

Department of Diagnostic Radiology
University of Toronto
Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS,
Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF; CREST
Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1;363(1):11-23. doi:
10.1056/NEJMoa0912321. Epub 2010 May 26.

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