title: Carotid angiographic characteristics in the CREST trial were major contributors to periprocedural stroke and death differences between carotid artery stenting and carotid endarterectomy.
abstract: OBJECTIVE
  The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated a higher periprocedural stroke and death (S+D) rate among patients randomized to carotid artery stenting (CAS) than to carotid endarterectomy (CEA). Herein, we seek factors that affect the CAS-CEA treatment differences and potentially to identify a subgroup of patients for whom CAS and CEA have equivalent periprocedural S+D risk.
  
  
  METHODS
  Patient and arterial characteristics were assessed as effect modifiers of the CAS-CEA treatment difference in 2502 patients by the addition of factor-by-treatment interaction terms to a logistic regression model.
  
  
  RESULTS
  Lesion length and lesions that were contiguous or were sequential and noncontiguous extending remote from the bulb were identified as influencing the CAS-to-CEA S+D treatment difference. For those with longer lesion length (≥12.85 mm), the risk of CAS was higher than that of CEA (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.19-9.78). Among patients with sequential or remote lesions extending beyond the bulb, the risk for S+D was higher for CAS relative to CEA (OR, 9.01; 95% CI, 1.20-67.8). For the 37% of patients with lesions that were both short and contiguous, the odds of S+D in those treated with CAS was nonsignificantly 28% lower than for CEA (OR, 0.72; 95% CI, 0.21-2.46).
  
  
  CONCLUSIONS
  The higher S+D risk for those treated with CAS appears to be largely isolated to those with longer lesion length and/or those with sequential and remote lesions. In the absence of those lesion characteristics, CAS appears to be as safe as CEA with regard to periprocedural risk of S+D.
authors.affiliation: Division of Vascular Surgery, UCLA Medical Center, Los Angeles, Calif.
authors.forename: Wesley S
authors.initials: WS
authors.lastname: Moore
authors.affiliation: Cardiac Service, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Popma
authors.affiliation: Cardiovascular Associates of the Southeast, Birmingham, Ala.
authors.forename: Gary S
authors.initials: GS
authors.lastname: Roubin
authors.affiliation: Department of Neurology, Medical University of South Carolina, MUSC Stroke Center, Charleston, SC.
authors.forename: Jenifer H
authors.initials: JH
authors.lastname: Voeks
authors.affiliation: Cardiac Service, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Donald E
authors.initials: DE
authors.lastname: Cutlip
authors.affiliation: Cardiology Associates at Central Baptist Hospital, Lexington, Ky.
authors.forename: Michael
authors.initials: M
authors.lastname: Jones
authors.affiliation: Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Ala.
authors.forename: George
authors.initials: G
authors.lastname: Howard
authors.affiliation: Department of Neurology, Mayo Clinic, Jacksonville, Fla; Department of Surgery, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ. Electronic address: brott.thomas@mayo.edu.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Brott
mesh_terms: D000368:Aged; D017130:Angioplasty / Q000009:adverse effects* / Q000295:instrumentation* / Q000401:mortality; D002339:Carotid Arteries / Q000000981:diagnostic imaging* / Q000601:surgery*; D016893:Carotid Stenosis / Q000000981:diagnostic imaging* / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D011237:Predictive Value of Tests; D011859:Radiography; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome