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ISC: Carotid surgery, stenting offer patients balanced alternatives

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10-year results document durable interventions

The 10-year CREST results are good news for patients with carotid disease because they show the durability of both interventions we can offer patients. Having these data and the results from ACT I allows physicians to have an informed discussion with patients about their treatment options. I also hope that with these results from both trials, reimbursement will cease to be a deciding factor and that both surgery and stenting will be on a level playing field for insurance coverage.

Although on a population level stenting and surgery appear to produce comparable results, individual patient characteristics can make one option more appropriate. These include the morphology of a patient’s carotid arteries and stenotic lesions that can make stenting a technical challenge, and a patient’s medical condition and comorbidities which could put them at higher risk for general anesthesia and surgery. Also, a big concern for many patients is how long they will require hospitalization.

Dr. Mark J. Alberts

A major unresolved question now about treating carotid disease is whether medical treatment alone is an equally good third alternative for asymptomatic patients. We are in a relatively new era of medical therapy, with more options for smoking cessation, better and more diverse drugs for blood pressure and hyperglycemia control, and wider use of high-dose statins. Some patients are eager to avoid any intervention and already opt for medical management only, but only after CREST-2 is completed will we know whether they will truly fare as well as patients who have a procedure performed.

Another issue that needs to be considered when extrapolating the results from CREST and ACT I to routine practice is that the surgeons and interventionalists who performed the procedures in these trials were highly selected and experienced. One cannot assume that the results in these trials will be replicated by any surgeon or interventionalist in the community. I suggest that patients investigate the track record of their community hospitals and operators by consulting the performance information that is increasingly posted on the Internet.

Dr. Mark J. Alberts is professor of neurology and medical director of the neurology service at the University of Texas Southwestern Medical Center in Dallas. He had no disclosures. He made these comments in an interview.


 

AT THE INTERNATIONAL STROKE CONFERENCE

References

LOS ANGELES – The equipoise between carotid stenting and endarterectomy received a further boost in 10-year results from the landmark Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) that compared the two options head-to-head.

Reported the day after results from another big trial that pitted carotid stenting against surgery, the Asymptomatic Carotid Trial (ACT I), the new long-term results from the CREST study mean that deciding among the options relies largely on patient preference although individual clinical characteristics might favor one approach or the other, experts said.

Dr. Thomas G. Brott Mitchel L. Zoler/Frontline Medical News

Dr. Thomas G. Brott

The big remaining unknown and wild card is whether doing no procedural intervention at all and relying entirely on optimal, contemporary medical treatment works just as well as endarterectomy or carotid stenting. The role for stand-alone medical therapy against carotid surgery or stenting (on top of medical therapy) is currently undergoing a formal, direct comparison in the randomized Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2).

Taking the 5-year outcome results from ACT I and the 10-year outcome results from CREST both into account, “we now have a lot of evidence that both carotid stenting and surgery are safe and durable. The results support both options” for either patients with symptomatic carotid artery stenosis or asymptomatic patients with carotid stenosis as extensive as in the patients enrolled in these trials, said Dr. Thomas G. Brott at the International Stroke Conference.

“In routine practice, we lay out the options of endarterectomy, carotid stenting, or no intervention with just medical treatment to patients and let them decide,” noted Dr. Brott, professor of neurology and director of research at the Mayo Clinic in Jacksonville, Fla.

CREST randomized 2,502 symptomatic or asymptomatic patients with significant carotid stenosis during 2000-2008 at 117 U.S. and Canadian centers. From this group, 1,607 consented and were available for long-term follow-up, done at a median of 7.4 years and as long as 10 years after follow-up.

The study’s primary, long-term endpoint was stroke, MI, or death during the periprocedural period (30 days after treatment or 36 days after enrollment depending on when the procedural intervention occurred) plus the rate of ipsilateral stroke during up to 10 years of follow-up. This combined endpoint occurred in 10% of the patients who underwent endarterectomy and in 12% of those who had stenting, a difference that was not statistically significant, Dr. Brott reported. Concurrent with his presentation at the meeting, sponsored by the American Heart Association, the results also were published online (N Engl J Med. 2016 Feb 18. doi: 10.1056/NEJMoa1505215).

The results included a secondary endpoint that showed a significant benefit for endarterectomy. The tally of periprocedural strokes or deaths plus ipsilateral strokes during 10-year follow-up was 8% for the surgical group and 11% for those who received a stent, a 37% excess hazard with stenting.

Dr. Brott attributed this secondary difference between the two arms of the study to a statistically significant excess of stroke or death during the periprocedural period in the patients treated by stenting, and more specifically an excess of strokes. The rate of total periprocedural strokes was 4% with stenting and 2% with endarterectomy, a statistically significant difference. Although an embolic protection device was used “when feasible” during stenting, this protection can be fallible, Dr. Brott noted. In contrast, the results from the ACT I trial showed no statistically significant difference in the rate of periprocedural total strokes between the stented and endarterectomy patients.

Dr. Brott had no relevant disclosures. The CREST trial received partial funding from Abbott Vascular.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

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