ST. LOUIS – Stenting and surgery are equally effective at lowering the long-term risk of stroke from a narrowed carotid artery, according to results of CREST – a 10-year, federally funded clinical trial led by researchers at Mayo Clinic’s campus in Florida. The results were published recently online in the New England Journal of Medicine. Mercy Hospital St. Louis was instrumental in the study as the sixth highest enrollment site.
One of the largest randomized stroke prevention trials ever, CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) conducted a study of 2,502 patients with an average age of 69 for up to 10 years at 117 centers in the U.S. and Canada. The study found the risk for stroke after either stenting or surgery (endarterectomy) was about 7 percent. The 10-year comparisons of restenosis (re-narrowing of the carotid artery) were low for both stenting and surgery – about 1 percent per year. Equal benefit was found for older and younger individuals, men and women, patients who had previously had a stroke and those who had not.
“This very low rate shows these two procedures are safe and are also very durable in preventing stroke,” says CREST principal investigator Thomas G. Brott, M.D., a neurologist and the Eugene and Marcia Applebaum Professor of Neurosciences on Mayo Clinic’s campus in Florida. “Because Medicare-age patients with carotid narrowing are living longer, the durability of stenting and surgery will be reassuring to the patients and their families.”
Despite the results of CREST, the question of the best way to manage stroke risk has not been answered yet. Because of that, CREST-2 was launched in December 2014 to compare stenting and surgery to medical management. CREST-2, which is expected to end in 2022, is being funded by a $39.5 million grant from the National Institute of Neurological Disorders and Stroke.
“Medicines have advanced dramatically since 1995 when we first looked at surgery versus medical management for these patients,” said Dr. Scott Westfall, Mercy Clinic vascular surgeon and principal investigator for CREST-2 at Mercy. “This study is significant to determine the best approach to care for patients with carotid stenosis and no stroke symptoms.”
The carotid surgery and carotid stenting procedures in CREST-2 will only be performed by doctors who have demonstrated safety and expertise in the procedures. Of the study participants assigned to carotid revascularization, about half will receive carotid endarterectomy and about half will receive a carotid stent. All participants will receive intensive medical management.
Dr. Westfall heads the team at the Mercy. Mercy Clinic vascular surgeons Drs. Vito Mantese and Richard Pennell are also approved surgeons for the trial. Other doctors involved on the medical management team include Mercy Clinic Drs. William Logan, neurologist; Timothy Schloss, interventional cardiologist; David Rempe, neurologist; and neurology nurse practitioner Marnie Donohoo.
Over the past 20 years, medical management of stroke risk factors has improved such that risk of stroke from asymptomatic carotid stenosis has been significantly reduced. Carotid endarterectomy and carotid stenting (both revascularization procedures) have also improved. To date, no research has been conducted to compare the treatment differences between medical management and these two procedures.
For questions about CREST-2 or to see if you qualify, please call Mercy Hospital St. Louis Research Institute at 314-251-7899.