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Patients randomized to carotid stenting had more periprocedural events than those treated with endarterectomy, but outcomes from either therapy at 10 years were indistinguishable, according to the long-term results of CREST.

The combined rate of between stenting patients and those who received endarterectomy (11.8% stenting versus 9.9% endarterectomy, HR 1.10, 95% CI 0.80-1.44).

Nor was there any clear difference between groups for ipsilateral stroke at 10 years (6.9% versus 5.6%, HR 0.99, 95% CI 0.64-1.52), , of Mayo Clinic in Jacksonville, Fla., and colleagues reported at the International Stroke Conference in Los Angeles, with simultaneous publication online in the New England Journal of Medicine.

These long-term findings "did not show significant differences between carotid-artery stenting and carotid endarterectomy" over a time period appropriate for elderly patients with severe carotid artery disease, they concluded.

Only time will tell if the patterns diverge due to changes in technology. For now, proximal embolic protection and mesh-covered stents are promising gains for stenting, according to the authors. "These and other anticipated advancements may lower the rates of periprocedural stroke," they wrote.

CREST enrolled 2,502 patients with symptomatic or asymptomatic carotid stenosis from 2000 to 2008.

The stenting group was not more likely to have adverse outcomes in the long run whether patients were symptomatic (HR 1.17, 95% CI 0.82-1.66) or asymptomatic (HR 0.99, 95% CI 0.64-1.52).

In the periprocedural period, however, the stented cohort suffered from higher rates of stroke or death (4.4% versus 2.3% for surgery, HR 1.37, 95% CI 1.01-1.86) and minor stroke alone (3.2% versus 1.7%, HR 1.95, 95% CI 1.15-3.30). On the other hand, the periprocedural period favored stenting for myocardial infarction (1.1% versus 2.3%, HR 0.50, 95% CI 0.26-0.94).

Remaining to be solved, however, is the "vexed question" of how to treat an asymptomatic patient, according to , of Western University in London, Ontario, and , of Leicester Royal Infirmary in England.

In an accompanying editorial, the pair argued that including only cases from the best interventionists and surgeons in CREST -- and similar trials such as ACT I -- did not reflect real-world scenarios, where many practitioners "are performing two or fewer procedures annually in asymptomatic patients, with poorer outcomes than their more experienced colleagues."

They added that, in the modern era, medical treatment has been suggested to lower stroke occurrence to rates on par with those associated with stenting or surgery. Thus, "outside clinical trials, endarterectomy and stenting should be reserved for patients with symptomatic severe stenosis or for asymptomatic patients who are shown to be at a higher risk for stroke with medical therapy than with intervention," they wrote.

The current CREST-2 trial seeks to assess the role of medical therapy in asymptomatic participants, Brott and colleagues noted.