SVS Comments on CREST and ICSS Studies

March 17, 2010—The Society for Vascular Surgery (SVS) released a statement on the recently reported results of CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) and ICSS (International Carotid Stenting Study) comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS) and supported the continued use of CEA over CAS for treating carotid artery disease.

SVS advised that several fine points of the studies must be appreciated and incorporated into the practices of vascular surgeons. The differing results of the studies make it important that physicians carefully and impartially balance their recommendations for treatment based on the condition of each individual patient.

According to the SVS, there are some important similarities and differences between these two trials. Both CREST and ICSS demonstrated a major improvement in the results of CEA over previously reported randomized trials. The stroke and death rate for symptomatic patients undergoing CEA in CREST was almost half of what was reported in the previous National Institutes of Health trial (NASCET [North American Symptomatic Carotid Endarterectomy Trial]), and in ICSS, the rate was almost half of what was reported in the earlier European Carotid Surgery trial. This is consistent with the excellent results of CEA as reported from many sources including administrative database studies and regional and national registries such as the National Surgical Quality Improvement Program.

ICSS concluded that endarterectomy had fewer complications than stenting and was therefore the preferred treatment; both strokes and heart attacks occurred more frequently after stenting. CREST showed that these two procedures were equivalent when all complications (stroke, heart attack, and death) were measured together. However, the SVS statement emphasized its belief that the primary and most important aim of CEA or CAS is to prevent stroke, and strokes occurred more frequently after stenting. Although heart attacks occurred more frequently after endarterectomy, they appeared to be minor, affecting quality of life less than the strokes as determined by SF-36 quality-of-life study in CREST. Finally, because ICSS allowed the use of all approved stent devices, SVS feels that its results are going to be more reflective of routine clinical practice. CREST allowed the use of only one device, and its strict credentialing process for interventionists served to produce a “best-case scenario” for CAS, the SVS stated.

“We believe that both CAS and CEA are useful tools for preventing stroke, but we believe that the majority of patients are still best served by CEA rather than CAS,” concluded SVS president Anton Sidawy, MD. “We are reassured that vascular surgeons have adopted the new technology of CAS because low complication rates can be achieved in a carefully selected subgroup of patients.”