This year’s meeting of Neurosurgery’s Joint Cerebrovascular Section was as interesting as ever. Dr. E. Sander Connolly was invited to give a talk on CREST, a research study about carotid artery stenosis.
Dr. Connolly opened his talk by explaining the vigorous debates surrounding the CREST and CREST-2 trials.
These two studies set out to compare treatments for carotid artery stenosis. In carotid artery stenosis, the carotid arteries in the neck narrow, usually due to plaque buildup. This can put people at a much higher risk for having a stroke. One way to treat this problem is “medically;” that is, using medications. A class of drugs called statins has been used widely in recent years, and can be used alone or with other treatments.
Another treatment method is called stenting. Stenting is a minimally invasive procedure in which surgeons use an artery in the leg to thread a catheter up into the carotid artery. They place a stent, or piece of tubing, in the carotid artery to keep it open.
Finally, a procedure called endarterectomy is the most invasive but also the most thorough. In this procedure, surgeons dissect the carotid artery in the neck, open it, and remove the plaque.
Doctors and patients would love to know which option is best for which cases. But carotid artery stenosis is a very complicated condition. Treatment plans must always be carefully personalized for individual patients. Many factors can affect the disease’s progression, a treatment’s effectiveness, and a patient’s recovery. A study that can’t separate all these nuances will yield recommendations that aren’t helpful to doctors or patients.
While the original CREST trial took many such factors into account, some people feel that its scope could have been larger. That’s why Dr. Connolly was interested in helping to design the follow-up study, CREST-2. He believes that with proper planning and review, most of the “pitfalls and perils” of studying such a complicated disease can be overcome.
In his talk, Dr. Connolly carefully presented some potential problems with the design of CREST-2. Many had to do with the nuances of individual treatments for individual patients. For example, he pointed out that the study would need to take into account “all that we know about…radiological subclassifications of Natural History Risk, TCD/CO2, and plaque morphology.” He explained each potential problem and detailed what could be done to solve it.
He ended his talk by engaging directly with his audience. Even with such a complicated study, he concluded, it is possible to avoid “pitfalls and perils.” But it will take careful, thoughtful work from people in many different groups. It will depend on the researchers who plan and direct the study, the reviewers who critique and approve it for publication, and the physicians who will interpret and use its results.
Learn more about Dr. E. Sander Connolly on his bio page here.
Related:
Neurosurgery Chair Dr. Robert Solomon To Give 2015 Luessenhop Lecture
Articles about the first CREST trial:
Dr. Solomon Comments On Wall Street Journal Stroke Article: Drugs V Stents
Solomon Responds To Trial Results For Treatment Of Carotid Artery Disease
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