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1. Journal Club
Stenting versus Endarterectomy for
Treatment of Carotid-Artery Stenosis
Carotid Revascularization
Endarterectomy vs. Stenting
Trial (CREST)
Thomas G. Brott, Robert W. Hobson,
George Howard et al.
Presented by Ram Kumar Shrestha
2. Background
85 % of all strokes are ischemic type.(Donan GA et al: stroke
Lancet 2008)
Carotid artery atherosclerosis is an important
cause of Ischemic Stroke accounting for 30-60%
Strokes due to carotid bifurcation occlusive
disease usually is caused by atheroemoli
Athersclerosis- stenosis- turbulent flow-
atheroembolization
3. Severity of Stenosis a/c luminal diameter
reduction
Mild <50 %
Moderate 50-69%
Severe 70-99%
Severe Carotid Stenosis is a strong predictor
for stroke. (Chaer RA, Derubertis et al – current mx of extracranial carotid artery disease:
2006)
A prior history of neurologic symptoms (TIA
or stroke) is an important determinant of
recurrent ipsilateral stroke. (3-17% 90 Day
risk of stroke) (Donan GA et al: stroke Lancet 2008)
4. Medical Therapy Vs
Surgical Therapy
Symptomatic Carotid Stenosis
European Carotid Surgery Trial (Warlow CP: Symtomatic patient: ESCT 1993)
North American Symptomatic carotid endarterectomy Trial (Kita MW: carotid endarterectomy in
symtomatic stenosis: NASCET comprative results at 30 months 1992)
Significant risk reduction in stroke for patients treated
surgically
Cumulative risk of ipsilateral stroke 26% in medical
therapy alone vs 9% in surgically treated groups at
2 years- severe carotid stenosis
22% vs 16% in moderate carotid stenosis
5. Medical Therapy Vs
Surgical Therapy
Asymtomatic Carotid Stenosis
Asymtomatic Carotid Atherosclerosis Study-
relative risk reduction of 53% by Carotid
Endarterectomy (>60 % stenosis)
( Fischer M et al NASCET-ACAS Plaque Project 1993)
Asymptomatic Carotid Surgery Trial- 11% vs
5.1% - similar result (>70% stenosis)
(Halliday A et al Lancet 2004)
6. Surgical Modalities
Carotid Endarterectomy (CEA)
Carotid Artery Stenting (CAS)-
minimal invasive technique
treatment alternative in patient deemed
high risk for cardiac endarterectomy
Severe cardiac disease
Severe pulmonary disease
Age >80 yrs
Anatomic criteria
Yadav et al: the SAPPHIRE TRIAL 2004 –
equivalency of two procedure
7. Surgical Modalities
Coward LJ et al – cochrane review
5 RCT before 2006
CAS associated with greater procedural risk of stroke
and death.
Greater incidence of Carotid restenosis
Meta-analysis by Quereshi found no difference in
stroke or death with CAS vs CEA Qureshi AI, Kirmani JF, Divani
AA et al. Carotid angioplasty with or without stent placement versus carotid endarterectomy for
treatment of carotid stenosis: a meta-analysis. Neurosurgery 2005;56(6):1171
8. AIM
Primary Aim of Carotid Revascularization
Endarterectomy vs. Stenting Trial was to
compare the outcome of CAS with those
of CEA among patients with symptomatic
or asymptomatic extracranial carotid
stenosis
9. Methods
Study Design: RCT
Centre: multicentric 108 centre in USA and 9 in
Canada
Period: dec 2000 july 2008
Total no of patient considered: 2522
10.
Study Patients:
Symtomatic: TIA, amaurosis
fugax or minor nondisabling
stroke involving study carotid
artery within 180 days before
randomization
Stenosis of >=50% in
angiography, =>70 in USG, or
=>70 in CTA,MRA if USG
stenosis 50-69%
12. Excluded:
Previous stroke severe enough to confound the
endpoints
Chronic AF
Paroxysmal AF within preceding 6 mths
needing use of anticoagulation therapy,
MI within prev 30 days
unstable angina
13. Clinical and anatomical Suitability were
considered for study revascularization
technique before randomization.
14. Randomization:
Web based system
Permuated block design (random block
size of 2,4 or 6)
Stratified according to centre and
symptomatic status
15. Stenting and Endarterectomy
Performed according to published guidelines
For CAS – Abbot's Rx Acculink stent and Rx
Accunet embolic Protection device
used
Preoperative and Postoperative antiplatelet
therapy
Treatment for HTN and hyperlipidaemia –
current standard of care
16. Primary End Points
Periprocedural
Stroke
MI
Death
Ipsilateral stroke within 4 years of
randomization
17. definition
Periprocedural Period: Period from randomization
through 30 days after the procedure
Stroke: acute neurologic event with focal
symptoms and signs, >24 hrs, consistent with
focal cerebral ischemia
Major Stroke was defined as major stroke on
the basis of clinical data or if the NIHSS score
was 9 or higher 90 days after the procedure.
18. MI:
CKMB or Troponin level twice upper
limit of normal range
Chest pain or symptoms consistent with
ischemia
ECG evidence of ischemia
19. F/u assessment of end
points
Neurologic Assessment
NIHSS
Modified Rankin Scale
TIA-Stroke Questionnaire
Baseline, 18-54 hr post op, 1 month, every
6 month thereafter
20. Cardiac Enzyme level
Before procedure, 6-8 hr after procedure
ECG before procedure, 6-48 hrs, 1 month
Carotid USG: before procedure, 1,6,12
months afterward and annually thereafter
27. Discussion
CREST Result: Similar rates of the primary
composite outcome- periprocedural stroke, MI, or
death and subsequent ipsilateral stroke- among
men and women with either symptomatic or
asymptomatic carotid stenosis.
Incidence of periprocedural stroke lower in
endarterectomy group
Periprocedural MI was lower in Stenting group.
28. Age needed to be considered when
selecting for CAS.
Younger patient have slightly better
outcome owing to vascular tortuosity and
severe vascular calcification
(Stingele R et al : a subanalysis of SPACE study. Lancet Neurol 2008,
Ederley J et al ICSS Lancet 2010)
29. Symptomatic patient Asymptomatic Patient
Study Rate of death or stroke
study Rate of death or stroke
CREST 6.0% CREST 2.5%
CAS SPACE 6.8% ACAS 2.3%
EVA-3S 9.6% ACST 3.1%
ICSS 7.4%
CREST 3.2% CREST 1.4%
CEA
SPACE 6.3% ACAS 1.8%
EVA-3S 3.9% ACST 2.2%
ICSS -
30. Rates of ipsilateral stroke during follow up:
Clinical durability
CAS 2.0% CEA 2.4%
Similar to SPACE trial and EVA-3S
Excellent durability upto 4 years
31. Limitation
1.Use of medical therapy alone not studied
2.Use of only one system Rx Acculink by
Abbot might affect external validity
3.Addition of asymptomatic patient
compromised the statistical power due to
low event rate in asymptomatic group
32. Conclusion
Carotid Revascularization by qulaified surgeon and
interventionist is effective and safe.
Stroke was more likely after CAS and MI was more
likely after CEA
Younger patients had slightly fewer events after
CAS compared to elderly.
Low absolute risk of recurrent strokes after CEA
and CAS suggest durability of both methods and
reflect advances in medical therapy
