VEITHsymposium 2010 Highlights: Moving on from CREST

VDM speaks with Wesley S. Moore, MD, Professor and Chief Emeritus, Division of Vascular Surgery at UCLA Medical Center. At the 2010 VEITHsymposium, Dr. Moore discussed the need for a moratorium on both CEA and CAS to make way for a new trial that will determine the best treatment option for patients with carotid stenosis.
 

What are the current implications of the CREST (Carotid Revascularization Endarterectomy vs. Stenting Trial ) results? Why is there still debate about this trial?

There is still debate about CREST because interventionists choose to look at the combined endpoints including myocardial infarction to say that carotid artery stenting (CAS) and carotid endarterectomy (CEA) yield equivalent results, and surgeons regard the main objectives to be stroke prevention, with CAS leading to nearly twice as many strokes as CEA procedures.

How does CREST differ from the yet-to-be-completed TACIT (Transatlantic Asymptomatic Carotid Intervention Trial) study? What, in your view, is lacking in these two trials? TACIT has not started and may be folded into CREST II. That study will address only the asymptomatic patient and will include a medical treatment arm.

What would the ideal trial design look like to adequately settle the matter on CAS versus CEA in symptomatic and asymptomatic patients?

I think that the issue of symptomatic patients has been settled when one looks at all the trials including the European, international and CREST trials in aggregate. A new trial is needed for asymptomatic patients, which will be a three-way comparison of CEA, CAS and medical management.

Medical therapy with statins and ACE inhibitors has improved for patients with carotid stenosis. How does this play in to the debate about the optimum treatment and how would this be incorporated into a new trial?

See my comments above. Optimum medical management alone should be compared with optimum medical management plus either CEA or CAS.

With what is currently known and based on your clinical experience, where do you stand in the CAS vs. CEA debate? When should CAS be performed, in your view?

CAS should continue to be performed in high-risk symptomatic patients.

Which procedure is more cost effective?

CEA has been shown to be less costly than CAS.

What is the current status on CMS coverage for CAS?

At the present time, the CMS will only cover CAS in symptomatic high-risk patients.

How do you see the treatment of carotid disease evolving in the coming decade?

CAS will become safer than it is now, perhaps by using a direct cervical approach and avoiding complications involving the diseased aortic arch.

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About VEITHsymposium: Now in its fourth decade, VEITHsymposium provides vascular surgeons, interventional radiologists, interventional cardiologists and other vascular specialists with a unique and exciting format to learn the most current information about what is new and important in the treatment of vascular disease. The 5-day event features over 400 rapid-fire presentations from world-renowned vascular specialists with emphasis on the latest advances, changing concepts in diagnosis and management, pressing controversies and new techniques. For more information about VEITHsymposium, visit: www.veithsymposium.org