In May 26, 2010 issue of NEJM, the much awaited paper was published, dealing with a well planned trial directly comparing carotid endarterectomy and carotid stenting
The results are not surprising: both are equally efficacious with minimal and comparable complications except that more heart attacks were seen in CEA group and more 'brain attacks' in CS.

Stenting versus Endarterectomy   for Treatment of Carotid-Artery Stenosis

Thomas G. Brott, M.D., Robert W. Hobson, II, M.D.,* George Howard, Dr.P.H.,
Gary S. Roubin, M.D., Ph.D., Wayne M. Clark, M.D., William Brooks, M.D.,
Ariane Mackey, M.D., Michael D. Hill, M.D., Pierre P. Leimgruber, M.D.,
Alice J. Sheffet, Ph.D., Virginia J. Howard, Ph.D., Wesley S. Moore, M.D.,
Jenifer H. Voeks, Ph.D., L. Nelson Hopkins, M.D., Donald E. Cutlip, M.D.,
David J. Cohen, M.D., Jeffrey J. Popma, M.D., Robert D. Ferguson, M.D.,
Stanley N. Cohen, M.D., Joseph L. Blackshear, M.D., Frank L. Silver, M.D.,
J.P. Mohr, M.D., Brajesh K. Lal, M.D., and James F. Meschia, M.D.,
for the CREST Investigators†
10.1056/nejmoa0912321


ABSTRACT
BACKGROUND
Carotid-artery stenting and carotid endarterectomy are both options for treating
carotid-artery stenosis, an important cause of stroke.
METHODS
We randomly assigned patients with symptomatic or asymptomatic carotid stenosis
to undergo carotid-artery stenting or carotid endarterectomy. The primary compos-
ite end point was stroke, myocardial infarction, or death from any cause during the
periprocedural period or any ipsilateral stroke within 4 years after randomization.
RESULTS
For 2502 patients over a median follow-up period of 2.5 years, there was no significant
difference in the estimated 4-year rates of the primary end point between the stenting
group and the endarterectomy group (7.2% and 6.8%, respectively; hazard ratio with
stenting, 1.11; 95% confidence interval, 0.81 to 1.51; P  =  0.51). There was no differen-
tial treatment effect with regard to the primary end point according to symptomatic
status (P  =  0.84) or sex (P  =  0.34). The 4-year rate of stroke or death was 6.4% with stent-
ing and 4.7% with endarterectomy (hazard ratio, 1.50; P  =  0.03); the rates among symp-
tomatic patients were 8.0% and 6.4% (hazard ratio, 1.37; P  =  0.14), and the rates among

asymptomatic patients were 4.5% and 2.7% (hazard ratio, 1.86; P  =  0.07), respectively.
Periprocedural rates of individual components of the end points differed between the
stenting group and the endarterectomy group: for death (0.7% vs. 0.3%, P  =  0.18), for
stroke (4.1% vs. 2.3%, P  =  0.01), and for myocardial infarction (1.1% vs. 2.3%, P  =  0.03).
After this period, the incidences of ipsilateral stroke with stenting and with endar-
terectomy were similarly low (2.0% and 2.4%, respectively; P  =  0.85).
CONCLUSIONS
Among patients with symptomatic or asymptomatic carotid stenosis, the risk of the
composite primary outcome of stroke, myocardial infarction, or death did not differ
significantly in the group undergoing carotid-artery stenting and the group undergo-
ing carotid endarterectomy. During the periprocedural period, there was a higher risk
of stroke with stenting and a higher risk of myocardial infarction with endarterec-
tomy. (ClinicalTrials.gov number, NCT00004732.)

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