Life after CREST: Impact on my carotid practice
- Mon, 3/14/11 - 11:29am
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A little over a year has passed since the CREST trial results were first announced (in February 2010). A great deal of information has been presented and published since then, and it would be most appropriate to acknowledge that this was a landmark trial. Some experts have gone as far as advancing the label of “the essence of evidence-based medicine” to describe its unique and history-making nature.
Most of us — whoever “us” may be — felt the clinical outcomes achieved by the CREST investigators were outstanding, both in the CEA and CAS arms. But particularly for CAS, the results were truly better than many experts had expected in the setting of a multicenter huge randomized trial. Count me in this group as well.
Forward now to March 2011: are we doing anything different, or “behaving” differently when facing carotid stenosis patients in need of intervention? Well, I suppose this may be impacted greatly by one’s specialty background. I am a vascular surgeon who has gained a great deal of confidence (over the many years) with both CEA and CAS, so I do not feel much different today than I did in January 2010. Still, today, I feel very uneasy to undertake CAS on patients with a history of recent (< 2 weeks) hemispheric symptoms, unsuitable arch and carotid bifurcation anatomies, extensive and pre-occlusive carotid lesions, and those who are over the age of 70. No change.
I am convinced that CAS is a great interventional approach for asymptomatic patients and those who have suitable access anatomy and favorable carotid lesions, as well as individuals with hostile necks and other anatomical contraindications to surgical CEA.
I would really like to hear other voices and experiences. How has CREST changed your indications, if at all, and your behavior vis-à-vis CAS vs. CEA?
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Dr. Frank J Criado is a Board-Certified Vascular Surgeon and Endovascular Specialist at the Union Memorial Hospital-MedStar Health in Baltimore, Maryland – USA. Dr. Criado is widely acknowledged to be a pioneer in endovascular therapy, with a 20-year + interventional experience. He has contributed extensively to the literature with more than 100 peer-reviewed published articles – mostly on various vascular and endovascular subjects, and Editor-in-Chief of Vascular Disease Management (VDM). He has also been active in clinical research, with a major focus on aortic stent-graft and carotid interventions, and endovascular technologies in general. He was the National Principal Investigator (P.I.) for the Medtronic Talent AAA clinical trials in the U.S., and a member of the Executive Committee for the Medtronic Valor Thoracic trial. He is a founding member and immediate past President of the International Society of Endovascular Specialists (ISES), founder and current President of the endovascular surgery society of Latinamerica (CELA), and a member of all major U.S. and international vascular and endovascular societies. He is a Fellow of the American College of Surgeons (FACS) and of the Society of Vascular Medicine (FSVM), and a member of the Board of Directors of the Society for Vascular Surgery (SVS).
Frank,
I agree that in general the results of CREST have not changed my approach to patients with extra-cranial carotid disease. We have always had the utmost respect for CEA as it is a proven surgical technique when done by an experienced operator in a select group of patients at standard risk for CEA
Carotid revascularization strategies, in particular CAS, revolve around two crucial things for successful patient outcomes:
1. Appropriate patient selection
2. Operator experience
Your point is well taken and understanding that there are "high risk" CAS patients is important as we are limited still to this day by complex arch and lesion anatomy including excessive calcification, tortuosity and gross thrombus.
However, we do perform with confidence CAS for symptomatic patients, recent TIA and the elderly. In those patients we do prefer to utilize the generational flow reversal technology that allows treatment of the lesion without ever having to manipulate the high risk lesion until the ipsi-lateral hemisphere is protected.748L5
It has been effective for patients but does require another level of operator sophisticiation, a careful review of intra-cranial anatomy with regard to the circle of willis, and a ultimately a patient that will tolerate flow cessation/reversal.
All the best and thank you for your timely initiation of this discussion.
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