CREST lead-in data: multiple stents associated with increased stroke rates

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Speaking at the recent annual meeting of the Society for Vascular Surgery (SVS), in Baltimore, MD, Dr Robert W Hobson, UMDNJ-New Jersey Medical School, Newark, NJ, lead investigator from the NIH/ NINDS sponsored clinical trial Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) revealed some interesting data from the CREST Lead-In study.

The purpose of his presentation was to report data from the CREST lead-in phase to determine the impact of the number of stents used in carotid artery stenting on 30-day stroke rates. Hobson said that while factors such as patient age, history of diabetes, anatomic anomalies (type III aortic arch, primary atherosclerotic lesions, arterial tortuosity, stenoses =90%, string sign) or intra-arterial thrombus are known to increase the risk associated with carotid artery stenting technical aspects may also be important and their influence on peri-procedural complications has not been well-defined.

The lead-in phase of CREST includes carotid artery stenosis procedures performed for symptomatic patients with =50% carotid stenosis, and asymptomatic patients with =70% stenosis. Data accrued from the inception of the registry in 2000 to 2006 were reviewed for number of stents deployed in each patient. The occurrence of 30-day stroke was recorded, as were demographic and clinical characteristics.

The registry included 1,303 patients, of which 26.6% (n=347) were symptomatic and 73.4% (n=956) were asymptomatic; 36.9% were women (n=481) while 63.1% (n=822) were men. The mean age of the cohort was 70.3 years, the mean stenosis treated was 85.7%. Additional demographic features included a history of diabetes (32.7%), coronary artery bypass surgery (24.4%), dyslipidemia (89.3%), current smoking (18.1%) and hypertension (84.4%). The majority of patients were <80 years old (88.9%) and most lesions treated had a mean diameter stenosis =80% (55.7%). Patient populations with 1 versus 2 or 3 stents exhibited no differences in demographics. Strokes were observed in 55 (4.2%) of 1,303 stenting procedures. A total of 46/55 (83.6%) strokes were associated with the use of a single stent, while 9/55 (16.4%) strokes had two (n=8) or three (n=1) stents. The 30-day stroke rate with one stent was 4.0% and with two or three stents was 13.2% (p=0.0002). Hobson concluded that these data confirm that a significant relationship exists between the number of stents used and procedural risk of carotid stenting: “Our results emphasize the importance of making every effort to utilize a single stent to cover the carotid lesion in CAS procedures.”