New stent procedure found to lessen stroke risk when treating carotid artery disease

Patients who are at risk of stroke have a less invasive option to surgery that seems to be equally as effective, according to a large-scale medical study.

A study called the Carotid Revascularization Endarterectomy Versus Stenting Trial showed that the previous gold standard of removing plaque from the carotid artery surgically will now share the throne with carotid stenting, which is newer and less invasive procedure in which a small wire mesh device is threaded into the carotid artery to keep it open.

"The CREST trial results show that we now have two safe and effective methods to treat carotid artery disease directly,"said Dr. Thomas Brott, professor of neurology at the Mayo Clinic in Jacksonville, Fla., and lead author of the study.

The results of the CREST study, which involved 2,502 patients at risk for stroke at more than 100 hospitals in the U.S. and Canada, were reported in February at the International Stroke Conference in San Antonio.

"CREST is a big-deal trial,"said Dr. Vishva Dev, director of cardiology at Los Robles Hospital & Medical Center in Thousand Oaks, Calif. "A game-changer."

UCLA Medical Center vascular surgeon Dr. Wesley Moore was a principal investigator of the CREST trial at UCLA, which was one of the hospitals where the trials were conducted. Moore said the CREST trial shows advantages and disadvantages of each procedure so that each patient and doctor can make an informed decision as to the best way to help prevent stroke or heart attack.

Among those who had surgery, 2.3 percent suffered later heart attacks as compared to 1.1 percent in the stenting group. In the stenting group, 4.1 percent suffered subsequent stroke as compared to 2.3 percent in the surgical group.

"Those patients who fear a stroke should select surgery since the incidence of stroke was almost twice as great in angioplasty (stenting),"Moore said. "And those patients who fear surgery can be considered for angioplasty (stenting) as long as they understand they are at increased risk for stroke."

"Stenting"describes the procedure in which a mesh-like closed spring is inserted into the artery through the groin. When the long tube reaches the blockage, the surgeon opens a balloon to clear the plaque, then opens the spring, propping open the artery. Stenting has been common inside the heart but not as common in the carotid artery, Dev said. However, he always thought it would effective in the carotid artery, too.

"I saw bypass surgery being replaced with stents so effectively, so I saw stents in the carotid artery as becoming the natural evolution,"Dev said.

An earlier stents vs. surgery study in 2004, called the Sapphire Study, showed that carotid stents were more effective for patients who were at higher risk for developing complications during surgery, but not necessarily for those at lower risk for surgical complications. This study puts carotid stenting on an equal footing with surgery for all patients with carotid artery blockage, including those with no symptoms warning of a stroke.

Herbert Weinberg of Westlake Village, Calif., 88, is doing well after Dev implanted a stent in his carotid artery earlier this month. Weinberg's carotid artery was 80 percent to 90 percent blocked. Dev went in through Weinberg's groin and implanted a carotid stent.

"I was falling asleep through most of it,"Weinberg said. "I don't remember much."

Dev said a magnetic resonance imaging scan done after the procedure showed that Weinberg's stent implant was successful.

The American Stroke Association reports that each year about 795,000 people experience strokes with about 610,000 being first attacks. About 137,000 die. The cost for treating strokes and disabilities caused by strokes in the U.S. will be about $73.7 billion, the ASA estimates.

Stroke ranks No. 3 among all causes of death behind heart disease and cancer, according to another organization called the National Stroke Association, the group that declared May as Stroke Awareness Month.

The CREST study was funded by the National Institute of Neurological Disorders and Stroke with supplemental funding by Abbott, an Illinois company that makes the stents.

The National Institute for Health Science reports that carotid stent procedures cost about $3,400 and surgery to remove plaque from the carotid artery costs about $5,400, although that cost can vary from hospital to hospital.

Kim Lamb Gregory writes for the Ventura County Star in California.