In addition, BMT has not been assessed in clinical trials for many years and has evolved substantially since that time with the development and growing use of statins, antiplatelet medications, beta-blockers, ACE inhibitors, calcium channel blockers, and others.
What is lacking is a randomized, controlled trial pitting all three treatments against one another in a head-to-head comparison of the most current techniques, the panel noted repeatedly.
"I think that drawing conclusions from indirect comparisons of things that were done in the past is incredibly hazardous and we need to have a contemporary direct comparison to know what the right thing to do is," argued panel member Dr. Larry B. Goldstein, who is a professor of neurology and director of the Duke Stroke Center in Chapel Hill, N.C.
Both surgery and CAS received a class I recommendation in guidelines published by the American Heart Association and other organizations in 2011 (J. Am. Coll. Cardiol. 2011;57:1002-44), but the level of evidence was stronger for CEA (level A) than for CAS (level B).
Planning is in the works for a possible CREST II trial in asymptomatic patients intended to compare intervention (with either CEA or CAS) vs. medical treatment alone. Many panel members expressed the need for this trial to proceed.
Twelve members of the panel reported that they did not have any relevant financial relationships. Dr. Spence reported receiving speaking fees from several pharmaceutical companies, Dr. Curtis reported that he owns stock in Medtronic and receives grant support from Boston Scientific, industry representative Dr. Peter Juhn works for Medco Health Solutions, and committee chair Dr. Clifford Goodman is the senior vice president at the Lewin Group, which has ties to both government and industry.