CREST: Restenosis Similar With Stenting and Surgery

Fran Lowry

August 23, 2012

August 23, 2012 — The results of a secondary analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), showing that rates of restenosis and occlusion after coronary artery stenting (CAS) and carotid endarterectomy (CAE) are similar, have now been published.

As presented by lead author Brajeshj Lal, MD, from the University of Maryland School of Medicine, Baltimore, at the International Stroke Conference (ISC) 2012 in February, and reported by Medscape Medical News, analysis of 2-year follow-up data yielded the following key findings:

  • CAS and CAE are associated with similar frequencies of restenosis in patients with symptomatic or asymptomatic carotid stenosis

  • Female sex, diabetes, and dyslipidemia are independent predictors of restenosis after CAS and CAE

  • Smoking is associated with an increased likelihood of restenosis after CAE

  • Restenosis is associated with increased risk for ipsilateral stroke after both CAS and CAE

These findings are published in the September issue of The Lancet Neurology.

The first CREST analysis, which was published in New England Journal of Medicine, showed no difference in the composite primary endpoint of stroke, myocardial infarction, or death during or after CAS and CAE.

In the secondary analysis, investigators assessed restenosis and occlusion by duplex ultrasonography at 1, 6, 12, 24, and 48 months, which were defined as a reduction in diameter of the target artery of at least 70%, diagnosed by a peak systolic velocity of at least 3.0 m/second.

Of 2191 included patients, 1086 received CAS and 1105 received CAE. In 2 years, 58 patients who underwent CAS (6.0%) and 62 patients who had CAE (6.3%) had restenosis or occlusion (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.63 - 1.29; P = .58).

Female sex, diabetes, and dyslipidemia were independent predictors of restenosis or occlusion after both procedures.

For women, the HR was 1.79 (95% CI, 1.25 - 2.56); for people with diabetes, the HR was 2.31 (95% CI, 1.61 - 3.31); and for those with dyslipidemia, the HR was 2.07 (95% CI, 1.01 - 4.26).

Smoking increased the risk for restenosis after CAE (HR, 2.26; 95% CI, 1.34 - 3.77) but not after CAS (HR, 0.77; 95% CI, 0.41 - 1.42).

In a statement, Dr. Lal commented that the results of the new analysis were "a huge surprise."

"For years, surgery has been the standard of care to unclog the carotids, and physicians have been reluctant to utilize carotid artery stenting because of lessons learned from stenting in the coronary arteries, which lead to the heart. Coronary blockages recurred 20 to 30 percent of the time after 1 to 3 years. The results of our study may help physicians and patients weigh the risks and benefits of these 2 carotid procedures, along with medical management, to come up with the best treatment options," he said.

Issues Remain

In an accompanying editorial, Leo H. Bonati, MD, of University Hospital Basel, Switzerland, notes that restriction of the main analysis of restenosis to the first 2 years after treatment in CREST is an important limitation, especially with regard to the long-term incidence of restenosis and its effect on future stroke.

"Less than half of the included patients were scanned up to 3 years, and less than a fifth up to 4 years, after treatment. Therefore, as the researchers point out, the 4-year estimates of restenosis or occlusion of 6.7% after carotid artery stenting and 6.2% after carotid endarterectomy should be interpreted with caution," Dr. Bonati writes.

This study was funded by the National Institute of Neurological Disorders and Stroke and by Abbott Vascular Solutions. Dr. Lal and Dr. Bonati have disclosed no relevant financial relationships.

Lancet Neurol. 2012;11:755-763. Article

Lancet Neurol. 2012;11:740-741. Editorial

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