The Carotid Revascularization Endarterectomy versus Stenting Trial: credentialing of interventionalists and final results of lead-in phase
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Updated: Jun 15, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
L Nelson Hopkins1, Gary S Roubin, Elie Y Chakhtoura
1Department of Neurosurgery, Millard Fillmore Hospital, University at Buffalo, State University of New York, Buffalo, New York, USA.
Insights
Rigorous training and credentialing for carotid artery stenting operators in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) ensured competent teams. This process minimized periprocedural stroke and death risks, ensuring reliable trial outcomes.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Medical Education
Background:
- Carotid artery stenting success relies on low periprocedural stroke and death rates.
- The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) required a competent interventionalist team.
- A rigorous training and credentialing process was essential for CREST participants.
Purpose of the Study:
- To detail the comprehensive training and credentialing process for interventionalists in the CREST trial.
- To evaluate the effectiveness of the credentialing process in selecting competent operators.
- To ensure fair comparison of outcomes between carotid endarterectomy and stenting.
Main Methods:
- A multidisciplinary committee evaluated 427 interventionalist applicants.
- Applicants underwent case review, training, and a lead-in phase.
- Selection for the randomized phase was based on experience, training, and lead-in results.
Main Results:
- 238 (56%) applicants entered training; 73 (17%) were exempt.
- 116 (27%) applicants did not qualify.
- Lead-in phase showed 30-day stroke/MI/death rates of 6.1% (symptomatic) and 4.8% (asymptomatic).
- Stroke or death rates were 5.8% (symptomatic) and 3.8% (asymptomatic).
- Outcomes varied by age and operator training.
Conclusions:
- The CREST credentialing process was the most rigorous reported for an endovascular treatment trial.
- The process successfully identified competent operators for the randomized trial.
- This ensured reliable comparison of carotid endarterectomy and stenting outcomes.
Abstract:
The success of carotid artery stenting in preventing stroke requires a low risk of periprocedural stroke and death. A comprehensive training and credentialing process was prerequisite to the randomized Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) to assemble a competent team of interventionalists with low periprocedural event rates. Interventionalists submitted cases to a multidisciplinary Interventional Management Committee. This committee evaluated 427 applicants. Of these, 238 (56%) were selected to participate in the training program and the lead-in phase, 73 (17%) who had clinical registry experience and satisfactory results with the devices used in CREST were exempt from training and were approved for the randomized phase, and 116 (27%) did not qualify for training. At 30 days in the lead-in study, stroke, myocardial infarction, or death occurred in 6.1% of symptomatic subjects and 4.8% of asymptomatic subjects. Stroke or death occurred in 5.8% of symptomatic subjects and 3.8% of asymptomatic subjects. Outcomes were better for younger subjects and varied by operator training. Based on experience, training, and lead-in results, the Interventional Management Committee selected 224 interventionalists to participate in the randomized phase of CREST. We believe that the credentialing and training of interventionalists participating in CREST have been the most rigorous reported to date for any randomized trial evaluating endovascular treatments. The study identified competent operators, which ensured that the randomized trial results fairly contrasted outcomes between endarterectomy and stenting.