November 21, 2011 - Frank J. Veith, M.D., founder and chairman of the VEITH symposium, the William J. von Liebig Chair in Vascular Surgery, Cleveland Clinic and New York University Medical Center, took a strong position against the current guidelines of the American Heart Association (AHA) that support the use of carotid artery stenting (CAS), as opposed to the more traditional open carotid endarterectomy (CEA), to treat symptomatic carotid stenosis (CS) in low to moderate risk patients. Veith explained to an audience of his peers that an important clinical trial for CAS, the CREST (Carotid Revascularization Endarterectomy vs. Stent Trial), had results that appeared to show that the stent procedure (CAS) and the open surgical approach (CEA) were equivalent. Veith argued that the study was in fact flawed in several ways and that the AHA guideline was misguided.
The CREST study was designed to compare CEA and CAS in only symptomatic patients, but poor recruitment led to the inclusion of some asymptomatic patients. Adding these patients to the pool diluted the intended power of the original study, as asymptomatic patients with carotid stenosis have a different pathology and natural disease history. The study’s primary endpoint included death, stroke and myocardial infarction, and the difference in this combination endpoint for the CAS and CEA groups was in fact not significantly different. But Veith pointed out that when the individual endpoints (like total, major and minor strokes) were individually examined there were large differences in the incidence of these events in the two groups. However, since the additional asymptomatic patients had been added to the study population, these important findings were not significantly different and the AHA concluded from the results that the two procedures had similar results and therefore CAS could now be viewed as an alternative.
There were other challenges with the design and conduct of the study, including that the skills of the CAS physicians in this study were superior to and not representative of those doing the procedure in the “real world.” In addition, the CAS patients received more intensive antiplatelet treatment that the CEA patients, leading to possibly a lower MI rate after CAS.
Veith’s main assertion was that, because CAS causes more strokes than CEA, CAS is currently inferior to CEA, and CAS should not be considered an alternative or equivalent to CAE in most symptomatic patients and therefore the AHA guidelines are “misguided.”
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