• Nicole R Gonzales, Bart M Demaerschalk, Jenifer H Voeks, MeeLee Tom, George Howard, Alice J Sheffet, Lawrence Garcia, Daniel G Clair, John Barr, Steven Orlow, Thomas G Brott, and CREST Investigators.
• From the Department of Neurology, University of Texas Science Health Center, Houston (N.R.G.); Department of Neurology, Mayo Clinic, Scottsdale, AZ (B.M.D.); Department of Neurosciences, Medical University of South Carolina, Medical University of South Carolina Stroke Center, Charleston (J.H.V.); Department of Surgery, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark (M.T., A.J.S., T.G.B.); Department of Epidemiology, University of Alabama at Birmingham (G.H.); Division of Cardiology and Vascular Medicine, Interventional Cardiology, Steward St. Elizabeth's Medical Center, Boston, MA (L.G.); Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH (D.G.C.); Departments of Radiology and Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (J.B.); Department of Cardiology, Northern Indiana Research Alliance, Lutheran Hospital of Indiana, Ft. Wayne (S.O.); and Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.).
• Stroke. 2014 Nov 1; 45 (11): 3320-4.

Background And PurposeEvidence indicates that center volume of cases affects outcomes for both carotid endarterectomy and stenting. We evaluated the effect of enrollment volume by site on complication rates in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST).MethodsThe primary composite end point was any stroke, myocardial infarction, or death within 30 days or ipsilateral stroke in follow-up. The 477 approved surgeons performed >12 procedures per year with complication rates <3% for asymptomatic patients and <5% for symptomatic patients; 224 interventionists were certified after a rigorous 2 step credentialing process. CREST centers were divided into tertiles based on the number of patients enrolled into the study, with Group 1 sites enrolling <25 patients, Group 2 sites enrolling 25 to 51 patients, and Group 3 sites enrolling >51 patients. Differences in periprocedural event rates for the primary composite end point and its components were compared using logistic regression adjusting for age, sex, and symptomatic status within site-volume level.ResultsThe safety of carotid angioplasty and stenting and carotid endarterectomy did not vary by site-volume during the periprocedural period as indicated by occurrence of the primary end point (P=0.54) or by stroke and death (P=0.87). A trend toward an inverse relationship between center enrollment volume and complications was mitigated by adjustment for known risk factors.ConclusionsComplication rates were low in CREST and were not associated with center enrollment volume. The data are consistent with the value of rigorous training and credentialing in trials evaluating endovascular devices and surgical procedures.Clinical Trial Registration Urlhttp://www.clinicaltrials.gov. Unique identifier: NCT00004732.© 2014 American Heart Association, Inc.

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