For patients with carotid artery stenosis, percutaneous intervention with stenting is as good as surgery (carotid endarterectomy). This was the major finding of the recently completed Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) 1—with some qualifications.
CREST is the latest in a series of clinical trials of treatment of carotid stenosis that have generated reams of numbers and much debate. The topic of surgery vs percutaneous intervention is a moving target, as techniques evolve and improve. We believe the CREST results are valuable and should help inform decisions about treatment in the “real world.”
In this article, we offer a critical review of CREST, with a careful evaluation of its methods, results, and conclusions.
AN EVOLVING FIELD
Despite improvements in diagnosis and management, stroke remains one of the leading causes of morbidity and death in the United States, with an annual incidence of 780,000 cases and 270,000 deaths. 2,3
Randomized trials of stenting have had mixed results, leading the Centers for Medicare and Medicaid Services (CMS) to adopt strict reimbursement policies. Currently, CMS reimburses for stenting only in symptomatic cases with at least 50% carotid artery stenosis. It also reimburses for stenting in asymptomatic cases in patients at high risk with 80% or greater stenosis, but only if the patients are enrolled in ongoing clinical trials or registries.
CREST compared stenting with endarterectomy and provided important insights into each approach. 1
Endarterectomy is superior to medical therapy for symptomatic stenosis
First described in 1953, carotid endarterectomy became the most widely used invasive treatment for significant carotid stenosis. 9 Several studies have described patient subsets that benefit from this procedure.
NASCET (the North American Symptomatic Carotid Endarterectomy Trial) 10 assigned 2,226 patients with symptomatic stenosis (transient ischemic attack or stroke within the past 180 days) to medical management or endarterectomy.
Surgery was associated with a 65% lower rate of ipsilateral cerebral events in patients with 70% or greater stenosis. 10 Surgery was also found to be superior in patients with moderate disease (50% to 69% stenosis), but the difference only approached statistical significance. In patients with stenosis of less than 50%, the outcomes were similar with endarterectomy and medical management. 11
ECST (the European Carotid Surgery Trial) 12 included a similar population of 3,024 patients. Those with high-grade disease (stenosis ≥ 80%) had significantly better outcomes with endarterectomy, but in those with stenosis less than 70%, surgery was no better than drug therapy.