by Isabella Colonna
For our first paper of the month of 2026, we have selected Brott TG, Howard G, Lal BK, et al; CREST-2 Investigators. Medical Management and Revascularization for Asymptomatic Carotid Stenosis. N Engl J Med. 2025 Nov 21. doi: 10.1056/NEJMoa2508800. Epub ahead of print. PMID: 41269206.
The management of asymptomatic high-grade carotid artery stenosis varies across countries, and it remains unclear whether revascularisation combined with intensive medical therapy is superior to intensive medical therapy alone.
This paper reports the results of the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trials (CREST-2), which consist of two parallel, multicentre, observer-blinded trials comparing carotid artery stenting or carotid endarterectomy plus intensive medical therapy with intensive medical therapy alone in patients aged 35 years or older with asymptomatic high-grade (≥70%) carotid artery stenosis. The primary endpoint was a composite outcome of any stroke or death occurring from randomisation through day 44, as well as ipsilateral ischaemic stroke during the subsequent follow-up period of up to four years.
A total of 1,245 patients were randomised in the stenting trial (medical therapy alone, n = 629; stenting, n = 616), and 1,240 patients were randomised in the endarterectomy trial (medical therapy alone, n = 623; endarterectomy, n = 617). At four years, the cumulative incidence of the primary outcome was significantly lower in the stenting group than in the medical-therapy group (2.8% vs. 6.0%; p = 0.02), whereas no statistically significant difference was observed in the endarterectomy trial (3.7% in the endarterectomy group vs. 5.3% in the medical-therapy group; p = 0.24). From day 0 through day 44, seven strokes and one death occurred in the stenting group, whereas no strokes or deaths were observed in the medical-management group; in the endarterectomy trial, nine strokes occurred in the endarterectomy group compared with three strokes in the medical-therapy group. Beyond 44 days, ipsilateral ischaemic strokes occurred at an annual rate of 0.4% in the stenting group versus 1.7% in the medical-management group, and 0.5% in the endarterectomy group versus 1.3% in the medical-management group.
In summary, these findings suggest that in patients with high-grade asymptomatic carotid artery stenosis, carotid artery stenting—but not carotid endarterectomy—combined with intensive medical therapy is associated with a lower risk of the composite outcome of perioperative stroke or death or ipsilateral ischaemic stroke within four years compared with intensive medical therapy alone.
