CREST, ARUBA give long-term updates

By Eleanor McDermid

medwireNews: Today's late-breaking trials session at the International Stroke Conference featured the long-term results of CREST and ARUBA, both of which support the original trial findings.

CREST: questions left unanswered

Thomas Brott (Mayo Clinic, Jacksonville, Florida, USA) presented a 10-year CREST (Carotid Revascularization Endarterectomy vs Stenting Trial) update, which also appears in The New England Journal of Medicine.

He reported that the 1607 patients who consented to long-term follow-up showed similar rates of postprocedural ipsilateral stroke irrespective of whether they received carotid artery stenting (CAS) or carotid endarterectomy (CEA), at 6.9% and 5.6%, respectively. Restenosis occurred in a corresponding 12.2% and 9.7%, which was also not a significant difference.

In a linked editorial, J David Spence (Western University, London, Ontario, Canada) and A Ross Naylor (Leicester Royal Infirmary, UK) stress that neither ACT 1, which reported its findings yesterday, nor CREST have resolved the "vexed question of how best to treat the asymptomatic patient."

Although clearly demonstrating that CAS and CEA are broadly equivalent, the results were obtained using highly trained and credentialed operators, who achieved a "commendably low" periprocedural event rate that may be hard to obtain in usual clinical practice, they say.

Added to this is the improvement in optimal medical care since the trials were initiated, which could further erode any benefits of intervening in clinical practice. Given the recorded difficulties in recruiting patients to carotid intervention trials, the editorialists urge physicians to avoid stenting or surgery in asymptomatic patients outside of CREST 2.

"This restraint would not only spare patients from procedures that may be unnecessary, but it should also facilitate early completion of the trial", they say.

ARUBA: leave AVMs well alone

ARUBA (A Randomized trial of Unruptured Brain AVMs) aimed to determine whether intervention or medical management was the best course for patients with unruptured brain arteriovenous malformations (AVMs) but was stopped early, after an average follow-up of 33.3 months, because of poor outcomes in the intervention group.

And the long-term follow-up, after an average of 50.4 months, confirms the original findings, with Christian Stapf (Université de Montréal, Quebec, Canada) reporting a number needed to harm of just five.

In the intention-to-treat analysis, the rates of stroke or death were 35.3% among 116 patients in the intervention group versus 13.6% among 110 in the medical management group. And in the per protocol analysis, the corresponding rates were 40.6% among 106 patients versus 10.8% among 120 patients.

This gave a number needed to harm of just three, despite a high spontaneous annual haemorrhage rate of 2.1%. And the result was the same regardless of patient and AVM characteristics, and of the treatment modality used (endovascular, surgical, radiotherapy or multimodal).

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