Carotid Stenosis for Stroke Prevention: Both Surgery and Stenting Give Long Lasting Results

MedicalResearch.com Interview with:

Thomas G. Brott, M.D. Professor of neurology and director for research and The Eugene and Marcia Applebaum Professor of Neurosciences and James C. and Sarah K. Kennedy Dean for Research. Mayo Clinic in Jacksonville, Fla

Dr. Thomas Brott

Thomas G. Brott, M.D.
Professor of neurology and director for research and
The Eugene and Marcia Applebaum Professor of Neurosciences and James C. and Sarah K. Kennedy Dean for Research.
Mayo Clinic in Jacksonville, Fla

Medical Research: What is the background for this study? What are the main findings?

Dr. Brott: Revascularization for carotid artery stenosis is the accepted treatment for symptomatic patients with >50% stenosis and for asymptomatic patients with >70% stenosis.  The original CREST report in 2010 showed both surgery and stenting were the safe methods to treat severe carotid stenosis.  But the follow-up averaged 2.5 years and Medicare-age patients live for an average of 18-20 years.  These patients and their families needed to know if surgery and stenting are durable in preventing stroke.

CREST was designed to answer the questions of clinical and anatomic durability for the long-run.

Medical Research: What should clinicians and patients take away from your report?

Dr. Brott: Both Surgery and Stenting are exceptionally durable.  Stroke occurred in less than 1% of the CREST patients per year. Stroke on the side of the carotid artery that had been opened up was at the same rate as stroke on the side of the other carotid artery, implying the risk from the treated carotid plaque had been largely eliminated.  In fact, the stroke rate was about the same in the CREST patients, all of whom started out with severe carotid stenosis, as the stroke rate in the general population of Medicare age patients.

The long-term CREST results also showed that the rate of re-stenosis was very low after either surgery or stenting, about 1% per year.  Both of these procedures are anatomically durable.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Brott: Now we know that surgery and stenting are effective.  However, patients with asymptomatic carotid narrowing have been observed in North America and Europe to have have a low rate of stroke without surgery or stenting.  So future research needs to answer, for those asymptomatic patients with low risk to begin with, which of the 3 treatments is best?  Carotid Endarterectomy?  Carotid Stenting?  Or, is 21st Century medical management sufficient, without a procedure, to prevent stroke in these asymptomatic patients.

To answer these questions, 2 large mulicenter randomized trials are underway, CREST-2 in North America, and the European Carotid Surgery Trial-2 (ECST-2) in Europe. 

Medical Research: Is there anything else you would like to add?

Dr. Brott: Prevention of stroke is one of the major success stories in Public Health over the last generation.  Death from stroke has dropped over 40% over that time period. Cigarette smoking among Americans has plummeted and continues to decline.  Millions of Americans now have their blood pressure measured, are more aware when their blood pressure is too high, and are more likely than ever to have it treated effectively.  And control of lipids continues to improve with the use of statins.  The other risk factors for stroke have also been more effectively identified and treated.

Citation:

Long-Term Results of Stenting versus Endarterectomy for Carotid-Artery Stenosis

Thomas G. Brott, M.D., George Howard, Dr.P.H., Gary S. Roubin, M.D., Ph.D., James F. Meschia, M.D., Ariane Mackey, M.D., William Brooks, M.D., Wesley S. Moore, M.D., Michael D. Hill, M.D., Vito A. Mantese, M.D., Wayne M. Clark, M.D., Carlos H. Timaran, M.D., Donald Heck, M.D., Pierre P. Leimgruber, M.D., Alice J. Sheffet, Ph.D., Virginia J. Howard, Ph.D., Seemant Chaturvedi, M.D., Brajesh K. Lal, M.D., Jenifer H. Voeks, Ph.D., and Robert W. Hobson, II, M.D. for the CREST Investigators

February 18, 2016DOI: 10.1056/NEJMoa1505215

Thomas G. Brott, M.D. (2016). Carotid Stenosis for Stroke Prevention: Both Surgery and Stenting Give Long Last Results 

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