TY - JOUR
TI - Critique of the Carotid Revascularization Endarterectomy versus Stenting
Trial (CREST): Flaws in CREST and its Interpretation
AU - Paraskevas, K. I.
AU - Mikhailidis, D. P.
AU - Liapis, C. D.
AU - Veith, F.
AU - J.
JO - European Journal of Vascular and Endovascular Surgery
PY - 2013
VL - 45
TODO - 6
SP - 539-545
PB - W B SAUNDERS CO LTD
SN - 1078-5884, 1532-2165
TODO - 10.1016/j.ejvs.2013.03.014
TODO - Carotid endarterectomy; Carotid artery stenting; CREST; Carotid
stenosis; Stroke; Myocardial infarction
TODO - The Carotid Revascularization Endarterectomy versus Stenting Trial
(CREST) has been used to support the equivalence of carotid artery
stenting (CAS) and carotid endarterectomy (CEA) in the treatment of
carotid stenosis in both symptomatic and asymptomatic patients. This
inclusion of two different forms of the disease decreased the power and
significance of the CREST results and weakened the trial. Other flaws in
CREST were the equal weighting of mostly minor myocardial infarctions
(MIs) with strokes and death in the pen-procedural, composite ‘end’
point, but not in the 4-year, long-term ‘end’ point. Although CAS was
associated with 50% fewer pen-procedural MIs compared with CEA, there
were >2.5-fold more MIs after CAS than CEA at 4 years. The 4-year MI
rate, however, was not a component of the primary ‘end’ point.
Additionally, although the initial CREST report indicated that there was
no difference in the outcomes of CAS and CEA according to symptomatic
status or sex, subsequent subgroup analyses showed that CAS was
associated with significantly higher stroke and death rates than CEA in
symptomatic patients, in females and in individuals >= 65 year of age.
The present article will examine these and other flaws and the details
of CREST’s results derived from the trial’s preplanned subanalyses to
show why the claims that CREST demonstrates equivalence of the two
therapeutic procedures are unjustified. (C) 2013 European Society for
Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
ER -