Howard S. Kirshner, MD
In patients with extracranial carotid stenosis, what is the relative efficacy of carotid artery stenting (CAS) and carotid endarterectomy (CEA)?
Randomized controlled trial (Carotid Revascularization Endarterectomy vs Stenting Trial [CREST]). ClinicalTrials.gov NCT00004732.
Unclear allocation concealment.*
Blinded (endpoint adjudication committee).*
4 years (median 2.5 y).
108 centers in the USA and 9 centers in Canada.
2522 patients with symptomatic stenosis or asymptomatic stenosis (≥ 60% stenosis on angiography, ≥ 70% on US, or ≥ 80% on CTA or MRA if stenosis on US was 50% to 69%). Exclusion criteria were previous stroke that could confound outcome assessment, chronic atrial fibrillation, paroxysmal atrial fibrillation in the past 6 months or requiring anticoagulant therapy, myocardial infarction (MI) in the past 30 days, or unstable angina.
CAS, using the RX Acculink stent, and when feasible, the RX Accunet embolic-protection device (n = 1271), or CEA (n = 1251). Procedures were done by certified interventionists/surgeons.
Composite of stroke, MI, or death during the periprocedural period, or ipsilateral stroke within 4 years of randomization. A sample size of 2500 patients would have 90% power to detect an absolute between-group difference of 1.2%/y.
2322 patients (92%) completed follow-up. (2502 patients were included in the intention-to-treat analysis.)
CAS and CEA did not differ for the primary outcome at 4 years (Table). CAS had a higher risk for stroke during the periprocedural period (4.1% vs 2.3%, P = 0.01) and at 4 years (Table), and CEA had a higher risk for MI during the periprocedural period (Table).
In patients with carotid stenosis, carotid artery stenting and carotid endarterectomy did not differ for a composite of stroke, myocardial infarction, or death at 4 years.
Carotid artery stenting (CAS) vs endarterectomy (CEA) for carotid artery stenosis†
†NS = not significant; other abbreviations defined in Glossary. RRI, RRR, NNH, NNT, and CI calculated from hazard ratios and control event rates in article; analyses adjusted for age, sex, and symptomatic status.
‡Stroke, myocardial infarction, or death during the periprocedural period, or ipsilateral stroke within 4 y of randomization.
Kirshner HS. Stenting and endarterectomy for carotid artery stenosis did not differ for a composite of stroke, MI, or death. Ann Intern Med. ;153:JC5–12. doi: 10.7326/0003-4819-153-10-201011160-02012
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Published: Ann Intern Med. 2010;153(10):JC5-12.
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