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Solomon Responds to Trial Results for Treatment of Carotid Artery Disease

Two procedures used in the treatment of  Carotid Artery Disease, stenting and endarterectomy have been hotly debated amongst surgeons for years.  Now, a huge new study published in the New England Journal of Medicine (NEJM) has added to the fodder and Chair of our department, Dr.Robert A. Solomon weighs in on this new research.

The study entitled, Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis (also called  Carotid Revascularization Endarterectomy vs. Stenting Trial or CREST) encompassed nearly 2500 patients from 116 medical centers across the United States and Canada.

Dr. Solomon says, “The Crest trial is, in my opinion, the largest and best study comparing endarterectomy and stenting for carotid artery disease.”

Stenting is a minimally invasive technique  where surgeons access the Carotid artery in the neck through an artery in the groin, then a stent, or piece of tubing, is placed inside the artery to ensure that it stays open.  Endarterectomy is a more traditional surgical procedure where the artery is opened and the plaque is removed.

Solomon continues, “The results [of CREST] are very consistent with previous trials. Most importantly, when compared to carotid endarterectomy, carotid stenting is associated with a higher periprocedural risk of stroke or death, a difference that was still significant at 4 years. The increased risk of stroke with stenting was offset by an increased risk of myocardial infarction in the endarterectomy patients, but stroke has much greater longterm health consequences than heart attack.”

The authors of this newly published research overall found little difference between these two procedures in terms of major outcome including, incidences of stroke, heart attack, and death. There were a couple of minor differences worth noting, however.

According to the authors, “The incidence of periprocedural stroke was slightly lower in the endarterectomy group than in the stenting group, whereas the incidence of myocardial infarction (heart attack) was lower in the stenting group.”

Also, they said that younger patients had, “a slightly better outcome with carotid-artery stenting and older patients having a better outcome with carotid endarterectomy.”

Dr. Solomon said, “My interpretation of the Crest Trial is that it supports the way we practice here at Columbia University Medical Center. Carotid endarterectomy is the preferred treatment for most patients with carotid stenosis, especially older patients with symptoms of carotid blockage. There are many instances where surgery is not ideal, such as patients with radiation induced stenosis, recurrent stenosis after previous endarterectomy, stenosis that is near the skull base, and certain medical conditions that contraindicate open surgery. In these patients we are gratified that stenting has been shown to be a reasonable alternative to open surgical treatment.”

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