terça-feira, março 02, 2010
Obstrução da carótida: Aberta ou fechada?
Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST)
A total of 2,502 patients were randomized, of which 1,262 were randomized to CAS and 1,240 to CEA. Of the total, 1,326 were symptomatic, and the rest were asymptomatic. The majority of patients had risk factors for cardiovascular disease, including diabetes (30%), hypertension (85%), dyslipidemia (83%), current smokers (25%), and prior coronary artery bypass grafting (21%).
Preliminary findings indicate that the primary endpoint of death, myocardial infarction (MI), or stroke at 30 days plus ipsilateral stroke thereafter was similar between the two arms (7.2% vs. 6.8%, hazard ratio 1.11, 95% confidence interval 0.81-1.51, p = 0.51). The incidence of death, MI, or stroke at 30 days was similar between the two arms (5.2% vs. 4.5%, p = 0.38). Periprocedural strokes were higher in the CAS arm (4.1% vs. 2.3%, p = 0.01). However, the incidence of debilitating and major strokes was similar between the two arms (0.9% vs. 0.7%, p = 0.52). Minor strokes were more frequent in the CAS group (2.7% vs. 1.5%, p < 0.05). The incidence of MI was significantly lower in the CAS arm, as compared with the CEA arm (1.1% vs. 2.3%, p = 0.03). Cranial nerve palsies were also more common in the CEA arm (0.3% vs. 4.8%, p < 0.0001). Long-term follow-up suggested that the incidence of ipsilateral stroke after the periprocedural period (approximately 4 years of follow-up) was similar between the two arms (2.0% vs. 2.4%, p = 0.85).
Subgroup analyses suggested that there was no difference based on gender or prior stroke/transient ischemic attack (TIA) status. However, there seemed to be evidence of effect modification by age, such that patients ≤69 years did better with CAS, whereras those ≥70 years did better with CEA. Moreover, the younger the patient, the greater the benefit with CAS, and conversely, the older the patient, the greater the benefit with CEA.
The results of the CREST trial indicate that CAS is associated with similar 30-day outcomes, as compared with CEA in a contemporary population. The risk of minor strokes is higher with CAS, whereas the risk of MI is higher with CEA. Older patients derive more benefit from CEA, whereas younger patients derive more benefit from CAS.
Apesar do avanço da colocação de stent na carótida, a cirurgia aberte ainda é uma boa opção.