For decades, surgery has been considered the gold standard treatment for preventing stroke in patients with narrowed neck arteries.

But a new study, the largest so far to compare surgery with another procedure, indicates that less-invasive stenting is just as safe and effective.

The news is likely to reshape the medical landscape for treating stroke.

“We’re learning more about what procedure is best for each patient,” said Dr. L. Nelson Hopkins III, chief of neurosurgery at Kaleida Health and chairman of neurosurgery at the University at Buffalo.

The recent release of results of the nine-year trial marks a satisfying moment for Hopkins and the program he heads, one of the few in Buffalo with a reputation beyond the city.

In 1994, Hopkins was among the first physicians in the United States to use a stent to restore blood flow through the fatty plaque that can build up in the carotid arteries.

His team played a key role over the years in advancing stent technology and techniques for use in opening clogged carotids, as well as the tiny convoluted arteries of the brain.

Physicians at Millard Fillmore Hospital, for instance, recently became the first in the nation to remove a blood clot from a patient’s brain using a new type of stent made by ev3 Inc.

Hopkins served as one of the principal investigators in the latest study at 117 centers in the United States and Canada. His program also became the principal site of the required training for most of the more than 200 doctors who participated in the trial.

“The question is no longer whether we can use stents for preventing strokes. Now, it’s who is the best candidate,” he said.

Stroke occurs when a blood vessel that carries oxygen to the brain ruptures or clogs. Typically, cholesterol and fat build up on the inner lining of an artery, causing it to narrow in a process called atherosclerosis.

About 300,000 patients a year undergo an endarterectomy to cut open and clear out deposits in the carotids, the main arteries in the neck that supply blood to the brain.

In stenting, physicians enlarge the artery by inflating a tiny balloon delivered through a catheter and then advance a metal stent, resembling a very small spring of a retractable pen, to gird the vessel wall. They also deploy a tiny filter to catch any debris, an important advance in technology in recent years that has lowered the procedure’s risk of stroke.

Unlike surgery, patients who receive stents avoid anesthesia and a scar on the neck, and often go home the next day.

The study, known as the Carotid Revascularization Endarterectomy vs. Stenting Trial, or CREST, involved 2,502 patients. The results were largely the same overall for men and women, as well as for those who had previously suffered a stroke and those who had not.

But complication rates differed. Researchers reported more heart attacks in the surgery patients following the procedure compared with the stenting group, and more strokes in the stenting group.

But rates of stroke and death in the surgery and stent patients were the lowest ever recorded in a large stroke prevention study, a reflection of improvements in technology and surgeon training, Hopkins said.

The study also found that at about age 69 and younger, stenting results were slightly better, while for patients older than 70, surgical results were slightly superior to stenting.

Hopkins said CREST will encourage more physicians to use stents and attract more patients who fit the criteria for appropriate candidates.

“We’re likely to see stenting play a bigger but complementary role. Patient preference will drive the change,” he said.

Like so much of medicine, questions, nevertheless, remain.

Previous studies have favored endarterectomy; moreover, interim results of a European study released the same week as CREST reported higher rates of stroke, death and heart attacks in patients treated with stenting compared with surgery.

Hopkins said the key lesson of the European trial may be that experience at stenting counts a lot.

“Doctors in CREST had to be credentialed and submit the results of their work. Then they had to go through training. We wanted to standardize how we did the stents,” he said.

About 30,000 carotid stent procedures are performed annually in the United States, a number limited by Medicare’s coverage of only patients with stroke-related symptoms at high risk of complications from surgery. Hopkins and others argue that CREST offers the evidence to expand coverage to more patients.

“The limited reimbursement also has put the development of stents on hold. We need industry to pour more money into research,” said Hopkins, who serves as an adviser to just about every company in the stent business, including Abbott Laboratories, Cordis, ev3, Invotek and Boston Scientific.

CREST was funded by the National Institute of Neurological Disorders and Stroke, with supplemental funding from Abbott.

Hopkins’ advice to patients is to choose an experienced physician and obtain a second opinion.

“Stents will be the right choice for some patients, and surgery for others,” he said. “You can’t make a treatment decision based on your bias about a particular procedure.”