Friday, February 26, 2010

Stents and surgery both safe for prevention of stroke, study says


The CREST Trial found that two medical procedures designed to prevent future strokes are both equally safe and effective.

A new study of people at risk for stroke due to blockage of the carotid arteries showed that two medical procedures designed to prevent future strokes are both equally safe and effective. These findings give physicians more options in tailoring treatments for their patients at risk for stroke.

In the trial of 2,502 participants, carotid endarterectomy (CEA), a surgical procedure to clear blocked blood flow in the carotid artery of the neck - and the current standard treatment - was compared to carotid artery stenting (CAS), a newer and less invasive procedure that involves using a stent to widen the artery and a device to prevent dislodged plaques from traveling to the brain during the procedure.

The study’s results, presented Friday, February 26, 2010, at the International Stroke Conference, found that both stenting and surgical endarterectomy are safe and useful tools in the right setting for stroke prevention.Read about the study in the Boston Globe

“We have been waiting for the results of this trial for many years,” says Michael R. Jaff, DO, medical director of the Massachusetts General Hospital Vascular Center. “This rigorous, scientifically sound study has shown that in patients who are not at particularly high risk for complications from surgery, stent placement was just as good as surgery. This allows for physicians to personalize treatment for the individual patient, offering the treatment that is best for them.”

One of the largest randomized stroke prevention trials ever, the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) took place at 117 centers in the United States and Canada over a nine-year period. The Massachusetts General Hospital Vascular Center was one of these trial sites, led by Kenneth Rosenfield, MD, director of cardiac and vascular invasive services, and Richard Cambria, MD, chief of the division of vascular surgery.

Investigators found patient outcomes from the two procedures are largely the same for both men and women, and for patients who had previously had a stroke compared to those who had not. However, differences between surgery and stenting were discovered when investigators looked at the number of heart attacks and strokes suffered by patients in the weeks following the procedure. More people in the surgical group suffered heart attacks, 2.3 percent compared to 1.1 percent in the stenting group. Conversely, there were more minor strokes in the stenting group, 4.1 percent versus 2.3 percent for the surgical group

The study was designed to determine if the rate of heart attack, stroke, and death combined was higher with surgery or stent,” said Jaff. “CREST has demonstrated that the two procedures are equally safe and effective in preventing stroke. Until the entire dataset has been published, it is not appropriate to speculate about subsets of patients who will benefit from one versus the other procedure. However, patients and their physicians now can discuss the individual options and make the best decisions for them.”

The study also found that the age of the patient made a difference. Stenting results were slightly superior in patients age 69 and younger, and surgical results were better than stenting in patients older than 70.

The Mass General Vascular Center offers both treatment options through the Stroke and Carotid Artery Disease Program.

“Given the results of CREST, finding a program where all specialists collaborate to provide the best treatment for individual patients is critical. The MGH Vascular Center is the only program to offer collaboration among all seven specialties providing expert care in vascular disease,” said Jaff.

Stroke, the third leading cause of death in the United States, is caused by an interruption in blood flow to the brain by a clot or bleeding. The carotid arteries on each side of the neck are the major source of blood flow to the brain, and buildup of cholesterol in the walls of this artery is one cause of stroke.

The CREST trial was funded by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health, and led by investigators at Mayo Clinic, Jacksonville, Fla., and the University of Medicine and Dentistry of New Jersey in Newark.

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