Mediators of the age effect in the carotid revascularization endarterectomy versus stenting trial (CREST)

Jenifer H. Voeks, George Howard, Gary Roubin, Richard Farb, Donald Heck, William Logan, Mary Longbottom, Alice Sheffet, James F Meschia, Thomas G Brott

Research output: Contribution to journalArticle

13 Citations (Scopus)

Abstract

Background and Purpose-There is higher combined risk of stroke or death (S+D) at older ages with carotid stenting. We assess whether this can be attributed to patient or arterial characteristics that are in the pathway between older age and higher risk. Methods-Mediation analysis of selected patient (hypertension, diabetes mellitus, and dyslipidemia) and arterial characteristics assessed at the clinical sites and the core laboratory (plaque length, eccentric plaque, ulcerated plaque, percent stenosis, peak systolic velocity, and location) was performed in 1123 carotid artery stenting-treated patients in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). We assessed the association of age with these characteristics, the association of these characteristics with stroke risk, and the amount of mediation of the association of age on the combined risk of periprocedural S+D with adjustment for these factors. Results-Only plaque length as measured at the sites increased with age, was associated with increased S+D risk and significantly mediated the association of age on S+D risk. However, adjustment for plaque length attenuated the increased risk per 10 years of age from 1.72 (95% confidence interval, 1.26-2.37) to 1.66 (95% confidence interval, 1.20-2.29), accounting for only 8% of the increased risk. Conclusions-Plaque length seems to be in the pathway between older age and higher risk of S+D among carotid artery stenting-treated patients, but it mediated only 8% of the age effect excess risk of carotid artery stenting in CREST. Other factors and mechanisms underlying the age effect need to be identified as plaque length will not identify elderly patients for whom stenting is safe relative to endarterectomy.

Original languageEnglish (US)
Pages (from-to)2868-2873
Number of pages6
JournalStroke
Volume46
Issue number10
DOIs
StatePublished - 2015

Fingerprint

Carotid Endarterectomy
Carotid Arteries
Stroke
Confidence Intervals
Endarterectomy
Dyslipidemias
Diabetes Mellitus
Pathologic Constriction
Hypertension

Keywords

  • Age
  • Carotid arteries
  • Risk factors
  • Stents
  • Stroke

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Clinical Neurology
  • Advanced and Specialized Nursing

Cite this

Mediators of the age effect in the carotid revascularization endarterectomy versus stenting trial (CREST). / Voeks, Jenifer H.; Howard, George; Roubin, Gary; Farb, Richard; Heck, Donald; Logan, William; Longbottom, Mary; Sheffet, Alice; Meschia, James F; Brott, Thomas G.

In: Stroke, Vol. 46, No. 10, 2015, p. 2868-2873.

Research output: Contribution to journalArticle

Voeks, JH, Howard, G, Roubin, G, Farb, R, Heck, D, Logan, W, Longbottom, M, Sheffet, A, Meschia, JF & Brott, TG 2015, 'Mediators of the age effect in the carotid revascularization endarterectomy versus stenting trial (CREST)', Stroke, vol. 46, no. 10, pp. 2868-2873. https://doi.org/10.1161/STROKEAHA.115.009516
Voeks, Jenifer H. ; Howard, George ; Roubin, Gary ; Farb, Richard ; Heck, Donald ; Logan, William ; Longbottom, Mary ; Sheffet, Alice ; Meschia, James F ; Brott, Thomas G. / Mediators of the age effect in the carotid revascularization endarterectomy versus stenting trial (CREST). In: Stroke. 2015 ; Vol. 46, No. 10. pp. 2868-2873.
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AU - Voeks, Jenifer H.

AU - Howard, George

AU - Roubin, Gary

AU - Farb, Richard

AU - Heck, Donald

AU - Logan, William

AU - Longbottom, Mary

AU - Sheffet, Alice

AU - Meschia, James F

AU - Brott, Thomas G

PY - 2015

Y1 - 2015

N2 - Background and Purpose-There is higher combined risk of stroke or death (S+D) at older ages with carotid stenting. We assess whether this can be attributed to patient or arterial characteristics that are in the pathway between older age and higher risk. Methods-Mediation analysis of selected patient (hypertension, diabetes mellitus, and dyslipidemia) and arterial characteristics assessed at the clinical sites and the core laboratory (plaque length, eccentric plaque, ulcerated plaque, percent stenosis, peak systolic velocity, and location) was performed in 1123 carotid artery stenting-treated patients in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). We assessed the association of age with these characteristics, the association of these characteristics with stroke risk, and the amount of mediation of the association of age on the combined risk of periprocedural S+D with adjustment for these factors. Results-Only plaque length as measured at the sites increased with age, was associated with increased S+D risk and significantly mediated the association of age on S+D risk. However, adjustment for plaque length attenuated the increased risk per 10 years of age from 1.72 (95% confidence interval, 1.26-2.37) to 1.66 (95% confidence interval, 1.20-2.29), accounting for only 8% of the increased risk. Conclusions-Plaque length seems to be in the pathway between older age and higher risk of S+D among carotid artery stenting-treated patients, but it mediated only 8% of the age effect excess risk of carotid artery stenting in CREST. Other factors and mechanisms underlying the age effect need to be identified as plaque length will not identify elderly patients for whom stenting is safe relative to endarterectomy.

AB - Background and Purpose-There is higher combined risk of stroke or death (S+D) at older ages with carotid stenting. We assess whether this can be attributed to patient or arterial characteristics that are in the pathway between older age and higher risk. Methods-Mediation analysis of selected patient (hypertension, diabetes mellitus, and dyslipidemia) and arterial characteristics assessed at the clinical sites and the core laboratory (plaque length, eccentric plaque, ulcerated plaque, percent stenosis, peak systolic velocity, and location) was performed in 1123 carotid artery stenting-treated patients in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). We assessed the association of age with these characteristics, the association of these characteristics with stroke risk, and the amount of mediation of the association of age on the combined risk of periprocedural S+D with adjustment for these factors. Results-Only plaque length as measured at the sites increased with age, was associated with increased S+D risk and significantly mediated the association of age on S+D risk. However, adjustment for plaque length attenuated the increased risk per 10 years of age from 1.72 (95% confidence interval, 1.26-2.37) to 1.66 (95% confidence interval, 1.20-2.29), accounting for only 8% of the increased risk. Conclusions-Plaque length seems to be in the pathway between older age and higher risk of S+D among carotid artery stenting-treated patients, but it mediated only 8% of the age effect excess risk of carotid artery stenting in CREST. Other factors and mechanisms underlying the age effect need to be identified as plaque length will not identify elderly patients for whom stenting is safe relative to endarterectomy.

KW - Age

KW - Carotid arteries

KW - Risk factors

KW - Stents

KW - Stroke

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DO - 10.1161/STROKEAHA.115.009516

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JF - Stroke

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