Restenosis rates low in both stenting and endarterectomty CREST patients


Carotid artery revascularisation with stenting or endarterectomy was equally durable, according to results of a new analysis of the CREST trial presented at the American Stroke Association’s International Stroke Conference 2012 in New Orleans, USA.

Two years after the procedures, less than 6% of patients had developed restenosis, researchers said.

“Unlike bare metal stents placed in coronary arteries, where restenosis occurs about 20% of the time, we found the re-blockage rates in the carotid artery were quite small,” said Brajesh K Lal, lead author of this analysis and associate professor of vascular surgery at the University of Maryland School of Medicine in Baltimore, USA. “Patients and physicians can be reassured that both procedures are durable and that restenosis rates are equivalent, so they can use different criteria to determine which procedure is right for a patient.”


The study is the largest to look at restenosis rates after either procedure. The study participants—part of CREST (Carotid Revascularization Endarterectomy versus Stenting Trial)—had partial carotid artery stenosis. Symptomatic patients had experienced a non-disabling stroke or transient ischaemic attack because of the blockage, while asymptomatic patients had not.


Previously, this head-to-head comparison of the two procedures showed no difference in the combined rates of stroke, heart attack or death between patients undergoing endarterectomy or stenting.


In the current study, 1,086 patients received stenting and 1,105 endarterectomy. Haemodynamically significant restenosis (≥70% diameter reduction) was defined by a peak systolic velocity ≥300 cm/second on standardised duplex ultrasonography, occlusion by an absence of flow within the target artery on duplex ultrasonography, and repeat revascularisation by any additional procedure performed on the index artery.


After two years, the researchers found identical rates of restenosis (5.8%) after stenting and endarterectomy. The rate of occlusion was 0.3% after stenting and 0.5% after endarterectomy. Combined restenosis/occlusion occurred in 6% patients after stenting and 6.3% after endarterectomy.


The investigators also found out that 20 stent patients and 23 endarterectomy patients had undergone a second revascularisation procedure. The results have also shown that rates of restenosis were about double in women and patients with diabetes and abnormal lipid levels. Stroke rates were four times higher in patients who developed a restenosis compared to those that did not develop a restenosis during follow-up.


“These may be groups we need to focus more on by monitoring them closely and aggressively controlling risk factors after the procedures,” said Lal, who is also chief of vascular surgery at the Baltimore VA Medical Center in Maryland.


In the study, results did not differ by operator’s specialty.


“CREST was unique in having a built-in training and credentialing process that mandated participating physicians perform 1,500 revascularisation procedures before randomising any patients,” Lal said.

“These results provide hard data for the FDA and professional societies to use as they recommend a particular type or extent of training for performing these procedures.”


The study is funded by the National Institute of Neurological Disorders and Stroke and Abbott Vascular, which included donations of the Acculink and Accunet stent systems to most of the CREST centres.