Differential outcomes of carotid stenting and endarterectomy performed exclusively by vascular surgeons in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

Abstract

Objective: Outcomes in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) did not differ between carotid artery stenting (CAS) and carotid endarterectomy (CEA) for the composite primary end point of stroke, myocardial infarction (MI), or death during the periprocedural period or ipsilateral stroke within 4 years. Rigorous credentialing and training of interventionists, including vascular surgeons, were required for the randomization phase of CREST. Because the lead-in phase of CREST had suggested higher perioperative risks after CAS performed by vascular surgeons, the purpose of this analysis was to examine differences in outcomes after randomization between CAS and CEA performed by vascular surgeons.

Methods: CREST is a prospective randomized controlled trial with blinded end point adjudication. Vascular surgeons performed 237 (21%) of the CAS procedures and 765 (65%) of the CEA procedures among 2320 patients who received their assigned treatment. Proportional hazards analyses were used to estimate the relative efficacy of CAS vs CEA for the composite primary end point and also for stroke and death.

Results: Among 2502 randomized patients, 1321 (53%) were symptomatic and 1181 (47%) were asymptomatic. For procedures performed exclusively by vascular surgeons, the primary end point did not differ between CAS and CEA at 4-year follow-up (6.2% vs 5.6%, respectively; hazard ratio [HR], 1.30; 95% confidence interval [CI], 0.70-2.41; P = .41) In this subgroup, the periprocedural stroke and death rates were higher after CAS than CEA for symptomatic patients (6.1% vs 1.3%; P = .01). Asymptomatic patients also had slightly higher stroke and death rates after CAS (2.6% vs 1.1%; P = .20), although this difference did not reach statistical significance. Conversely, cranial nerve injuries (0.0% vs 5.0%; P < .001) were less frequent after CAS than CEA. The MI rates were slightly lower after CAS (1.3% vs 2.6%; P = .24). In performing CAS, vascular surgeons had outcomes for the periprocedural primary end point comparable to the outcomes of all interventionists (HR, 0.99; 95% CI, 0.50-2.00) after adjusting for age, sex, and symptomatic status. Vascular surgeons also had similar results after CEA for the periprocedural primary end point compared with other surgeons (HR, 0.73; 95% CI, 0.42-1.27).

Conclusions: When performed by surgeons, CAS and CEA have similar net outcomes, although the periprocedural risks vary (lower stroke with CEA and lower MI with CAS). These data suggest that appropriately trained vascular surgeons may safely offer both CEA and CAS for the prevention of stroke. The remarkably low stroke and death rates after CEA performed by vascular surgeons in CREST, particularly among symptomatic patients, represent the best outcomes ever reported after carotid interventions from a randomized controlled trial. ClinicalTrials.gov identifier: NCT0000473.

Trial registration: ClinicalTrials.gov NCT00004732 NCT00000473 NCT00004732.

Figure 1

Perioperative stroke and death rate for carotid endarterectomy in symptomatic patients. CINC 1980=Cincinnati; CINC 1984; NASCET 1991=North American Symptomatic Carotid Endarterectomy Trial; NASCET 1998; CAVATAS=Carotid and Vertebral Artery Transluminal Angioplasty Study; SPACE=Stent-protected Angioplasty versus Carotid Endarterectomy trial; EVA-3S=Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis trial; ICSS=International Carotid Stenting Study; CREST=Carotid Revascularization Endarterectomy versus Stenting Trial; CREST by VS=CREST by vascular surgeons.

Figure 2

Perioperative stroke and death rate for carotid endarterectomy in asymptomatic patients. CINC 1980=Cincinnati; CINC 1984; ACAS=Asymptomatic Carotid Atherosclerosis Study; ACST=Asymptomatic Carotid Surgery Trial; CREST=Carotid Revascularization Endarterectomy versus Stenting Trial; CREST by VS=CREST by vascular surgeons.