The optimal management for asymptomatic carotid stenosis has been a subject of debate, particularly with advancements in medical therapy. New findings from the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) provide clarity, suggesting a benefit for carotid-artery stenting when added to intensive medical management.¹

Methodology

CREST-2 involved two parallel, observer-blinded clinical trials conducted across 155 centres in five countries. The trials enrolled patients with high-grade (≥70%) asymptomatic carotid stenosis.

The stenting trial (n=1245) compared carotid-artery stenting plus intensive medical management with intensive medical management alone. The endarterectomy trial (n=1240) compared carotid endarterectomy plus intensive medical management with intensive medical management alone.

The primary outcome for both trials was a composite of any stroke or death from randomisation to 44 days, or ipsilateral ischaemic stroke during the remaining follow-up period of up to 4 years.

Results

In the stenting trial, the 4-year incidence of the primary outcome was significantly lower in the stenting group compared to the medical-therapy group (2.8%; 95% CI, 1.5 to 4.3 vs 6.0%; 95% CI, 3.8 to 8.3; P=0.02). However, during the initial 44-day perioperative period, seven strokes and one death occurred in the stenting group, while no events occurred in the medical-therapy group.

In the endarterectomy trial, the difference in the 4-year incidence of primary outcome events was not statistically significant between the endarterectomy group and the medical-therapy group (3.7%; 95% CI, 2.1 to 5.5 vs 5.3%; 95% CI, 3.3 to 7.4; P=0.24). In the perioperative period, nine strokes occurred in the endarterectomy group versus three strokes in the medical-therapy group.

In Practice

The CREST-2 investigators concluded that, “Among patients with high-grade stenosis without recent symptoms, the addition of stenting led to a lower risk of a composite of perioperative stroke or death or ipsilateral stroke within 4 years than intensive medical management alone. Carotid endarterectomy did not lead to a significant benefit.”¹ These results suggest that for select asymptomatic patients, adding stenting to a robust medical regimen may reduce long-term stroke risk, though this is balanced by an initial procedural risk. The lack of a significant benefit for endarterectomy highlights the efficacy of modern intensive medical therapy alone in this patient population.²

This study was funded by the National Institute of Neurological Disorders and Stroke, the Centers for Medicare and Medicaid Services, and NIH StrokeNet.

References

1. Brott TG, Howard G, Lal BK, et al. Medical Management and Revascularization for Asymptomatic Carotid Stenosis. N Engl J Med 2026;394:219-231. https://doi.org/10.1056/NEJMoa2508800

2. Brown MM, Bonati LH. Managing Asymptomatic Carotid Stenosis. N Engl J Med 2025;394(3):296-297. https://doi.org/10.1056/NEJMe2515725

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