Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis

Abstract

Conclusion: In patients with symptomatic or asymptomatic carotid stenosis, a composite outcome of stroke, myocardial infarction, or death does not differ between patients undergoing endarterectomy or those undergoing carotid artery stenting. During the periprocedural period, there is a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy. Summary: The authors randomly assigned patients with asymptomatic or symptomatic carotid artery stenosis to undergo carotid endarterectomy or carotid artery stenting. The primary end point was a composite end point of stroke, myocardial infarction, or death from any cause during the periprocedural period or any ipsilateral stroke ≤4 years after randomization. There were 2502 patients participating in the study, with a median follow-up of 2.5 years. There were no significant differences in the estimated 4-year rates of the primary end point between the stenting group and the endarterectomy group (7.2% and 6.8%, respectively; hazard ratio with stenting, 1.11; 95% confidence interval, 0.81-1.51; P = .51). The primary end point did not differ according to sex (P = .34) or symptomatic status (P = .84). The 4-year rate of stroke or death was 6.4% with stenting and 4.7% with endarterectomy (hazard ratio, 1.37; P = .14). Rates among asymptomatic patients were 4.5% and 2.7%, respectively (hazard ratio, 1.86; P = .07). There were differences in periprocedural rates of individual components of the end points between the stenting and endarterectomy group. Rates of death for stenting were 0.7% vs 0.3% for endarterectomy (P = .18). Rates of stroke were 4.1% for stenting vs 2.3% for endarterectomy (P = .01). Rates of myocardial infarction were 1.1% for stenting vs 2.3% for endarterectomy (P = .03). After the periprocedural period, incidences of ipsilateral stroke with stenting and with endarterectomy were both low (2% vs 2.4%, respectively; P = .85). Comment: The CREST results are finally published. The question now is what do we do with them? The primary end point of the study, a combination of stroke, death, and myocardial infarction, did not differ between the stented and surgically treated patients (P = .38). This was secondary to a higher incidence of periprocedural myocardial infarction in the endarterectomy patients. Rates of stroke and death were higher in the stented group, both in the periprocedural period and out to 4 years (any stroke, P = .01; any periprocedural or postprocedural ipsilateral stroke, P = .01; any periprocedural stroke or death or postprocedural ipsilateral stroke; P = .0.005; Table 2 of the article). The results basically mirror those of other government-sponsored large randomized trials that favored endarterectomy over stenting for stroke prevention or failed to establish noninferiority of stenting (Ederle J, et al [Lancet 2010;375:985-97]; Mas J-L, et al [N Engl J Med 2006;355:1660-71]; and Ringleb PA, et al [Lancet 2006;368:1239-47]) Additional analysis in CREST indicated stroke had an adverse long-term outcome on quality of life, whereas perioperative myocardial infarction had no effect on quality of life measures. Overall it would seem the evidence favors endarterectomy over stenting, but this will surely continue to be debated.