Stroke after Carotid Stenting and Endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)
Background—Stroke occurs more commonly after carotid artery stenting than carotid endarterectomy. Details regarding stroke type, severity, and characteristics have not been previously reported. We describe the strokes occurring in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).
Methods and Results—CREST is a randomized, open-allocation, controlled trial with blinded endpoint adjudication. Stroke was a component of the primary composite outcome. Patients who received their assigned treatment within 30 days of randomization are included. Stroke was adjudicated by a panel of board-certified vascular neurologists with secondary central review of clinically-obtained brain images. Stroke type, laterality, timing, and outcome are reported. A periprocedural stroke occurred among 81 of the 2502 patients randomized and among 69 of the 2272 in this analysis. Strokes were predominantly minor (81%, n=56), ischemic (90%, n=62), in the anterior circulation (94%, n=65), and ipsilateral to the treated artery (88%, n=61). There were seven hemorrhages, occurring 3-21 days post-procedure, and five were fatal. Major stroke occurred in 13 (0·6%) of the 2272 patients. The estimated four-year mortality after stroke was 21·1% compared to 11·6% for those without stroke. The adjusted risk of death at four years was higher after periprocedural stroke (HR = 2·78, CI95 1·63-4·76).
Conclusions—Stroke, particularly severe stroke, was uncommon after carotid intervention in CREST, but stroke was associated with significant morbidity and was independently associated with a near threefold increased future mortality. The delayed timing of major and hemorrhagic stroke after revascularization suggests that these strokes may be preventable.
Clinical Trial Registration Information—ClinicalTrials.gov. Identifier: NCT00004732.
- Received May 23, 2012.
- Accepted November 1, 2012.
- Copyright © 2012, American Heart Association, Inc. All rights reserved. Unauthorized use prohibited