Changing the Landscape of Carotid Artery Disease Treatment

For decades, the medical community has deliberated what the right treatment is—or even if treatment is necessary—for patients with carotid artery disease, who don't have symptoms. Current treatment options include intensive medical management, either alone or in combination with revascularization. Revascularization includes procedures such as carotid artery stenting or carotid endarterectomy, a surgical procedure that removes plaque buildup in the carotid artery.

The CREST-2 trial is the first comprehensive trial to compare treatment differences between current medical management therapies and revascularization. The trial presents an opportunity for the medical community to reach a consensus on the most effective treatment for patients.

All participating centers faced challenges in enrolling and randomizing patients into different study arms. Many individuals with carotid artery disease feel fine and are reluctant to undergo invasive revascularization therapies. On the other hand, other patients strongly preferred revascularization over medical management alone.

Our success was a result of contributions from our entire team. We all recognized the importance of this trial, so each team member took the time to explain the details to patients, schedule multiple follow-up visits, and answer any questions they had. I’m particularly thankful to the Yale Vascular Surgery team, as well as Shannon Lynch, FNP, Amanda Pappas, RN, Dawn Shaddinger, RN, and our entire administrative staff, nurse practitioners, clinical fellows, and research coordinators. I am also grateful to Drs. Eric Velazquez and Alexandra Lansky, who supported our work throughout the trial.

Most of all, I am thankful to all the patients who participated in this trial. Their involvement is helping us learn how to prevent strokes and improve care for millions of people worldwide. This kind of scientific research would not be possible without them.

Now that we have evidence suggesting that treatment may lower the risk of stroke, should we increase screening for carotid artery disease? We do not yet have research to show that increased screening is appropriate, but further research is needed to help clarify this for the medical community.

I am also the site PI for CREST-H, a subgroup of the CREST-2 clinical trial. In this study, we are examining whether stent placements or endarterectomies can help improve cognitive function. Because carotid artery disease can restrict blood flow to the brain, some individuals with the condition may experience vascular cognitive impairment, which affects their ability to remember information or think clearly. For many patients, preventing or addressing cognitive loss is a priority for their care. I hope that through our research, we can determine whether treatments can improve cognitive function.