What are the treatment recommendations for carotid artery disease based on the Crest trial?

From the Guidelines

Treatment recommendations for carotid artery disease should prioritize carotid endarterectomy (CEA) over carotid artery stenting (CAS) for patients over 70 years old, while CAS may be considered for patients under 70, based on the CREST trial 1. The CREST trial demonstrated similar overall outcomes between CEA and CAS for the composite endpoint of stroke, myocardial infarction, and death, though CEA showed slightly lower stroke rates while CAS had fewer myocardial infarctions 1. Key considerations for treatment selection include:

• Symptomatic patients with recent TIA or stroke and carotid stenosis ≥50% should undergo intervention within 2 weeks of symptom onset 1
• Asymptomatic patients should be considered for intervention for stenosis ≥60-70% if the surgical risk is low and life expectancy exceeds 5 years 1
• Age is an important factor, with patients under 70 potentially benefiting more from CAS and those over 70 from CEA 1
• Optimal medical therapy should be provided to all patients, including antiplatelet therapy, high-intensity statin therapy, blood pressure control, and lifestyle modifications 1 The CREST trial's findings are supported by other guidelines, which emphasize the importance of individualized treatment decisions based on patient characteristics, anatomy, comorbidities, and surgical risk factors 1. Some key points to consider when making treatment decisions include:
• The periprocedural stroke rate was higher with CAS than with CEA (4.1% versus 2.3%; P=0.01) 1
• The periprocedural MI rate was lower with CAS than with CEA (1.1% versus 2.3%; P=0.03) 1
• Quality of life was impacted significantly by major and minor stroke but not by MI at 1 year 1
• Cranial nerve palsy was more common after CEA 1

From the Research

Treatment Recommendations for Carotid Artery Disease

Based on the Crest trial, the treatment recommendations for carotid artery disease are as follows:

• Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are both effective treatments for carotid stenosis, with equivalent composite outcomes 2, 3.
• The choice between CEA and CAS should be based on individual patient characteristics, such as symptomatic status, age, and comorbidities 4, 5.
• CEA is associated with a higher rate of periprocedural stroke, but a lower rate of overall inpatient mortality and readmission rates compared to CAS 4.
• CAS is associated with a higher rate of restenosis and myocardial infarction at 4 years compared to CEA 6.

Key Findings from the Crest Trial

• The Crest trial demonstrated no significant difference in the rates of composite outcome (stroke, myocardial infarction, or death) between CAS and CEA 2, 3.
• Subgroup analyses showed that CAS was associated with significantly higher stroke and death rates than CEA in symptomatic patients, females, and individuals ≥ 65 years of age 6.
• The trial had some flaws, including the equal weighting of mostly minor myocardial infarctions with strokes and death in the peri-procedural composite endpoint 6.

Implications for Clinical Practice

• The results of the Crest trial should be considered when making treatment decisions for patients with carotid artery disease 2, 4, 3, 5, 6.
• Clinicians should carefully evaluate individual patient characteristics and comorbidities when choosing between CEA and CAS.
• Further research is needed to fully understand the long-term outcomes and cost-effectiveness of CEA and CAS for carotid artery disease.