The management of high-grade asymptomatic carotid stenosis has long been controversial. Improvements in intensive medical management (IMM) have recently challenged the necessity of routine revascularization procedures. Therefore, the CREST-2 trials directly compared IMM alone with IMM plus either carotid-artery stenting (CAS) or carotid endarterectomy (CEA). This major study included patients with severe, non-symptomatic narrowing (≥70%). Ultimately, the results clarify the preferred therapeutic approach for these high-risk patients.
Asymptomatic Carotid Stenosis: Stenting Significantly Reduces Long-Term Stroke Risk
The stenting trial randomized 1245 patients to either IMM alone or IMM plus CAS. The primary outcome was a composite of stroke or death within 44 days or ipsilateral ischemic stroke over four years. Importantly, the addition of stenting to IMM led to a significantly lower rate of primary-outcome events at four years: 2.8% compared with 6.0% for IMM alone (P=0.02). Conversely, the CAS group did experience a higher number of perioperative events, including seven strokes and one death within the first 44 days, while the IMM group had none. Nonetheless, the long-term benefit clearly favored the stenting group. This superior outcome highlights the effectiveness of contemporary stenting techniques combined with aggressive medical therapy.
Endarterectomy Did Not Provide a Significant Benefit
The endarterectomy trial, which enrolled 1240 patients, demonstrated a different result. Carotid endarterectomy (CEA) combined with IMM did not yield a statistically significant benefit over IMM alone. The 4-year incidence of the primary outcome was 3.7% in the CEA group versus 5.3% in the IMM group (P=0.24). Furthermore, the CEA group also showed a higher perioperative stroke risk (nine strokes and no deaths) compared to the IMM-alone group (three strokes and no deaths). Since previous trials also failed to show a clear advantage, many experts now question the role of routine CEA for high-grade asymptomatic carotid stenosis.
Patients in both trials received intensive medical management. This management included rigorous control of risk factors like blood pressure, lipids, and diabetes. Earlier studies had already indicated that intensive medical therapy alone drastically lowers stroke risk compared to previous decades. Consequently, any revascularization procedure must now demonstrate an additional, substantial benefit beyond this high-level IMM. The CREST-2 stenting trial accomplished this benchmark.
Frequently Asked Questions
Q1: What was the main finding of the CREST-2 stenting trial?
The addition of carotid-artery stenting to intensive medical management significantly reduced the 4-year risk of the composite primary outcome (stroke or death) from 6.0% to 2.8% in patients with high-grade asymptomatic carotid stenosis.
Q2: Did carotid endarterectomy (CEA) show the same benefit?
No, the carotid endarterectomy trial did not find a statistically significant reduction in the primary outcome when comparing CEA plus intensive medical management (3.7%) with medical management alone (5.3%) over four years.
References
- Brott TG et al. Medical Management and Revascularization for Asymptomatic Carotid Stenosis. N Engl J Med. 2026 Jan 15. doi: 10.1056/NEJMoa2508800. PMID: 41269206.
- ACC.org. CREST-2: Stents But Not Endarterectomy Reduced Stroke Risk For Asymptomatic CAS.
- TCTMD. Long-Awaited CREST-2 Results Bolster Stents for Asymptomatic Carotid Stenosis.
- Journal of NeuroInterventional Surgery. CREST-2: percutaneous carotid stenting plus intensive medical therapy reduces stroke in asymptomatic patients.
- AHA Journals. Optimal Medical Management of Asymptomatic Carotid Stenosis.