CREST Trial

Vivien Williams: Carotid artery disease increases your risk of stroke. Plaque builds up in the arteries in the neck, and if some breaks away, it could travel to your brain and cut off blood flow. But results of a study published in the New England Journal of Medicine give doctors the information they need to choose the best preventive procedures for their patients.

It’s called the CREST Trial — Carotid Revascularization Endarterectomy versus Stent Trial. What that means is researchers tested open surgery versus stenting of the carotid artery to see which procedure was best at opening blockages and preventing stroke. Findings show that open surgery and stenting are equally safe and effective at preventing stroke, except for people over the age of 80.

Albert Hakaim, M.D.—Mayo Clinic vascular surgery: Based on the CREST Trial for patients who are older and the majority of vascular patients are older, carotid endarterectomy is superior to stentings.

Vivien Williams: Dr. Albert Hakaim says, people over 80 who have stents placed to open blockages in their carotid arteries have a higher risk of stroke after treatment than those who had the open operation. But if you’re younger, both procedures are equally beneficial.

You see, blockages happen after years of plaque buildup on the artery walls. If a piece breaks off, it could flow to the brain and cut off blood supply, causing stroke. Here’s a comparison of the two procedures.

First, the standard operation. With the patient under general anesthesia, Dr. Hakaim makes an incision in the neck to expose the carotid artery which carries blood to the face and brain. Then he inserts a temporary shunt to reroute blood so they can work on the artery. Next, he opens the artery lengthwise, removes plaque, and closes the incision.

Stenting is less invasive. With the patient having local anesthesia, Dr. Hakaim advances a catheter through the femoral artery in the leg up to the blockage. Just above it, he places a tiny umbrella shaped device to make sure that if the pieces of plaque break off they don’t flow to the brain. Then he deploys the stent, which is pushed into place by a balloon. The stent opens the artery and crushes the plaque against the artery wall.

Albert Hakaim, M.D.: So here’s the common carotid artery. And this is where the artery branches, so this branch goes to the face. This was the narrowing. This is the stent before the angioplasty.

Vivien Williams: Two procedures, both safe and effective at preventing stroke in the right groups of patients. The CREST Trial is important, because stroke is the third leading cause of death in the U.S. and the number one cause of disability. Now doctors can be more certain that the procedures they do for their patients will reduce the risk of stroke. For Medical Edge, I’m Vivien Williams.

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