Cath Lab Digest

The CREST results were eagerly anticipated for many years. We hoped that a prospective, randomized trial for carotid disease would clarify how people should be treated with high-grade carotid stenosis. I don’t think that the actual picture is as clear as we were hoping when the trial results were announced.

I think it is clear that there is a slightly higher risk of MI for surgical patients. But, there is a slightly lower risk of neurologic events in the surgical arm. It also seems that older patients (greater than 70 years old) do better with an operation.

So, have you changed your practice? I think mine is the same. I have the ability to stent or operate safely. I think this is the key point. You need to be able to provide either approach safely at your medical center. In other words, multiple specialties may be needed at some institutions in order to offer both services.

I choose my patients carefully for either approach. Some patients go to surgery and some receive a stent. In fact, I am not concerned about switching approaches for a given patient even if I have started on a different path. For example, a patient with a type III arch with an occluded external carotid artery is not a great stent candidate if the surgical risk is reasonable. Therefore, I would stop the procedure as a diagnostic angiogram and schedule a carotid endarterectomy.
I know this treatment remains in evolution for all of us. Please tell me what you think!

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Ross Milner, MD, FACS is associate professor of surgery at Loyola University Chicago Stritch School of Medicine. He was recruited to Loyola from Emory University School of Medicine in Atlanta, where he was associate professor of surgery.

Dr. Milner graduated Cum Laude from the University of Pennsylvania, where he also completed medical school. He was chief resident in surgery at the Hospital of the University of Pennsylvania. He completed fellowships at the University of Pennsylvania and University Medical Center in Utrecht in the Netherlands. Dr. Milner is currently Chief of the Division of Vascular Surgery and Endovascular Therapy at Loyola University Medical Center, Stritch School of Medicine in Chicago, Illinois.