Carotid artery stenting versus carotid endarterectomy: current status

The durability of carotid endarterectomy: long-term results for restenosis and stroke

BACKGROUND

Carotid endarterectomy is a low-risk treatment for carotid occlusive disease. Recent clinical trials have suggested that carotid angioplasty may be a viable alternative. One important issue that has not been evaluated is the long-term recurrent stenosis rate after either intervention.

OBJECTIVE

To examine the risk of recurrent stenosis after carotid endarterectomy and to provide long-term data on the durability of carotid endarterectomy.

METHODS

A total of 1335 sequential patients were followed up prospectively with annual carotid ultrasonography. All patients were maintained on antiplatelet therapy, and arteriotomies were closed with a patch graft. Operations were performed under general anesthesia with electroencephalographic monitoring and selective shunting. There were no changes in surgical technique during this study.

RESULTS

Two-thirds of the patients were men; the mean age was 70 years. Approximately 60% were symptomatic. The 90-day perioperative morbidity and mortality rate was 0.9% (0.4% stroke and 0.5% death). Five patients (0.4%) developed recurrent stenosis >70% over a mean follow-up of 15.8 years. Twelve patients (0.9%) had documentation of late stroke in the ipsilateral carotid distribution. The mean follow-up was 15.8 years.

CONCLUSION

Carotid endarterectomy is an extremely safe treatment for carotid stenosis with very low perioperative complications and low rates of recurrent stenosis or late stroke. When endarterectomy is compared with angioplasty, in addition to periprocedural complications, the durability of both interventions needs to be considered, given the risks and costs of repeat interventions.

Design of the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST)

RATIONALE

Carotid endarterectomy (CEA) and medical therapy were shown superior to medical therapy alone for symptomatic (> or =50%) and asymptomatic (> or =60%) stenosis. Carotid angioplasty stenting (CAS) offers a less invasive alternative. Establishing safety, efficacy, and durability of CAS requires rigorous comparison with CEA in symptomatic and asymptomatic patients.

AIMS

The objective is to compare the efficacy of CAS versus CEA in patients with symptomatic (> or =50%) or asymptomatic (> or =60%) extracranial carotid stenosis.

DESIGN

The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) is a prospective, randomized, parallel, two-arm, multi-center trial with blinded endpoint adjudication. Primary endpoints are analyzed using standard time-to-event statistical modeling with adjustment for major baseline covariates. Primary analysis is on an intent-to-treat basis.

STUDY OUTCOMES

The primary outcome is the occurrence of any stroke, myocardial infarction, or death during a 30-day peri-procedural period, and ipsilateral stroke during follow-up of up to four years. Secondary outcomes include restenosis and health-related quality of life.