Wednesday, July 13th 2011 2nd Journal Reading

Stroke. 2011;42:675-680
Moderator : dr. Dina Listyaningrum, Sp.S, Msi.Med Presenter : dr. Maria Thessarina Sitepu

Introduction
The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) compared CEA and CAS in symptomatic and asymptomatic pts.
The secondary analysis data compare the periprocedural complication of CEA and CAS in symptomatic and asymptomatic pts.

Methods
CREST a multicenter RCT w/ blinded end point adjudications that compared the safety and efficacy of CAS vs CEA.
Symptomatic patients had TIA or ischemic stroke ipsilateral to a stenosed carotid artery within 180 days.

Carotid Stenosis
Symptomatic Patients
50% by angiography 70% by duplex ultrasound 70% by CTA or MRA if the stenosis on ultrasonography 50% - 69%

Asymptomatic patients
60% by angiography 70% by ultrasound 80% by CTA or MRA if the stenosis on ultrasonography 50% - 69%

 Surgeon had to perform >12 CEAs annually

Interventionalists had to demostrate experience in

CAS, receive hands-on experience with the RX Acculink stent and the RX Accunet embolicprotection device , and/or successfully complete a lead-in phase
The primary end point was : stroke, MI, or death

Statistical Analyses
Intentionto-treat end point analyses were conducted using standart time-to-event statistical modeling.
The periprocedural as the 30-day period after the procedure for those participants receiving their assigned procedure within 30 days Or 36 days after randomization for those participants not receiving their assigned treatment within 30 days.

Results

Discussion
The periprocedural stroke and death rates for CAS and CEA are the lowest reported from populationbased studies.
Furthermore, these rates are within the target of <6% for symptomatic pts suggested in the recent AHA/ASA guidelines and <3% terget for asymptomatic pts.

 Periprocedural stroke and death are even lower when the pts aged 80 years are excluded. In the symptomatic pts the periprocedural risk of stroke and death significanly lower in surgeon performed CEA compared w/ the interventionalists performing CAS.

 This advantage of surgery was counterweighed by a higher MI rate and postoperative cranial nerve palsies.

Summary
CREST has demonstrated w/ experienced surgeons

and interventionalists both CAS and CEA are viable options for carotid revascularization.
Althouth the primary complication rate similar for

CEA and CAS in both symptomatic and asymptomatic pts the rate of stroke in the periprocedural period was higher for CAS for symptomatic pts.

Carotid stenting

Carotid Artery Stenting (CAS)

CAS

Figure 7- Diagram showing a catheter from the right common femoral artery into the distal internal carotid artery.

CAS