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Stenting or Surgery? Trial Says Both Equally Safe & Effective

The National Institutes of Health (NIH) landmark clinical trial in stroke prevention—the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST)—has recently released its results. Dartmouth-Hitchcock was part of the nine-year, potentially paradigm-shifting, study that compared the safety and efficacy of carotid endarterectomy (CEA), a surgical procedure to clear blocked blood flow, and carotid artery stenting (CAS). The results have shown that both stroke prevention procedures are equally safe and effective.

Surgery was considered the gold standard at preventing future strokes, although some smaller studies showed stenting was better. Richard Powell, MD, Professor of Surgery, Section of Vascular Surgery and Principal Investigator for the study at DHMC, says, "CREST really was the tie-breaker, and though it showed that in certain subsets of the population surgery is more effective and in certain subsets stenting is better, this study showed that both are equally safe and effective." The results, Powell says, are great news for patients. "Here at Dartmouth-Hitchcock where vascular surgery has a proven track record of doing both CEA and CAS, we can really individualize treatment for the best outcome for each patient."

James Schumann

CREST participant James Schumann and his wife, Wanda

James Schumann of Keene, N.H., received a stent as part of CREST. "Suddenly I had this line across my eye and I couldn't see of out of one eye," says Schumann, recalling what brought him to the Emergency Department five years ago. "Turns out a vessel had been shut off. Dr. Lukovits talked to me about the program. I wanted the stent, but I knew that it was a 50-50 chance I'd get the surgery."

It turned out that Schumann got what he wanted, and he couldn't be happier. "Getting the stent wasn't a hard procedure. I felt great when I went home and I've felt great since then. You feel comfortable when you learn that everything is fine."

Schumann also said that every follow-up visit was reassuring and thorough. "Dr. Powell and Dr. Lukovits are just excellent. They stay right on top of everything. I'd do it again the same way."

Hugh Sycamore of Hebron, N.H., discovered he had a blockage in his carotid artery at a routine check-up with his primary care physician in Plymouth, who sent him to DHMC.

"The blockage was in the 60-70 percent range and getting worse," Sycamore said. "I didn't really have a preference at the time for which procedure I received, but I was very glad to have conventional surgery."

Sycamore says he had no complications from the surgery in 2006 and has felt very good ever since. Additionally, Sycamore, a former hospital administrator, felt privileged to be part of such a well-run trial. "I was kept extremely well-informed about the trial and the results. I have the utmost respect for Dr. Powell and Dr. Lukovits."

Hugh Sycamore

CREST participant Hugh Sycamore

Powell explains that while deemed equally safe and effective, important differences in the procedures were teased out in the study: "For example, the study found that patients under the age of 68 generally do better with stenting, while patients greater than 68 generally do better with surgery."

Timothy Lukovits, MD, Medical Director of the Cerebrovascular Disease and Stroke Program at DHMC and the study neurologist adds, "This study also found that there was a slightly higher risk of heart attack following surgery and a slightly higher risk of stroke in the stent group in the periprocedural period. These outcomes were counted equally in the results but may differ greatly in their impact on a patient's quality of life. This aspect of the results has not been fully released yet and warrants further discussion."

The study, with joint NIH and industry funding, was conducted at 117 sites around the country. Sites selected had to prove a high degree of proficiency and safety with both procedures to be considered. "We had to have done 50 stents with good outcomes, which we had," Powell says. "We had a good track record with both procedures. And Dartmouth-Hitchcock has a unique perspective, in many sites stenting is done by cardiology or interventional radiology; here, vascular surgery does both procedures. We don't have a bias."

CREST enrolled 2,502 patients in the randomized trial—some with previous stroke history and some who were at risk but asymptomatic. Patients were followed for 30 days for immediate complications of stroke, heart attack and death, and for four years for future stroke events.

The trial was one of the largest stroke prevention trials ever. Being one of the sites participating in this landmark trial was important for Dartmouth-Hitchcock in many ways. "This was an excellent, tightly run trial and it was important for us regionally to be part of this," Lukovits says. "It was stimulating for the physicians and non-physicians and important training for fellows. It was also an excellent collaboration between neurology and vascular surgery."

Since both treatment options are available at Dartmouth-Hitchcock, Powell is excited about the ability to better tailor treatment to each individual. "While the results of CREST showed that the two procedures were equally safe and effective, we now better understand the strengths and weaknesses of both, which benefits each patient tremendously."

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