Carotid angiographic characteristics in the CREST trial were major contributors to periprocedural stroke and death differences between carotid artery stenting and carotid endarterectomy

J Vasc Surg. 2016 Apr;63(4):851-7, 858.e1. doi: 10.1016/j.jvs.2015.08.119. Epub 2015 Nov 21.

Abstract

Objective: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated a higher periprocedural stroke and death (S+D) rate among patients randomized to carotid artery stenting (CAS) than to carotid endarterectomy (CEA). Herein, we seek factors that affect the CAS-CEA treatment differences and potentially to identify a subgroup of patients for whom CAS and CEA have equivalent periprocedural S+D risk.

Methods: Patient and arterial characteristics were assessed as effect modifiers of the CAS-CEA treatment difference in 2502 patients by the addition of factor-by-treatment interaction terms to a logistic regression model.

Results: Lesion length and lesions that were contiguous or were sequential and noncontiguous extending remote from the bulb were identified as influencing the CAS-to-CEA S+D treatment difference. For those with longer lesion length (≥12.85 mm), the risk of CAS was higher than that of CEA (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.19-9.78). Among patients with sequential or remote lesions extending beyond the bulb, the risk for S+D was higher for CAS relative to CEA (OR, 9.01; 95% CI, 1.20-67.8). For the 37% of patients with lesions that were both short and contiguous, the odds of S+D in those treated with CAS was nonsignificantly 28% lower than for CEA (OR, 0.72; 95% CI, 0.21-2.46).

Conclusions: The higher S+D risk for those treated with CAS appears to be largely isolated to those with longer lesion length and/or those with sequential and remote lesions. In the absence of those lesion characteristics, CAS appears to be as safe as CEA with regard to periprocedural risk of S+D.

Trial registration: ClinicalTrials.gov NCT00004732.

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Angioplasty / adverse effects*
  • Angioplasty / instrumentation*
  • Angioplasty / mortality
  • Carotid Arteries / diagnostic imaging*
  • Carotid Arteries / surgery*
  • Carotid Stenosis / diagnostic imaging*
  • Carotid Stenosis / mortality
  • Carotid Stenosis / surgery
  • Carotid Stenosis / therapy*
  • Endarterectomy, Carotid / adverse effects*
  • Endarterectomy, Carotid / mortality
  • Female
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • Odds Ratio
  • Patient Selection
  • Predictive Value of Tests
  • Radiography
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Stents*
  • Stroke / diagnosis
  • Stroke / etiology*
  • Stroke / mortality
  • Time Factors
  • Treatment Outcome

Associated data

  • ClinicalTrials.gov/NCT00004732