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Clinical Question

Asymptomatic carotid stenosis: revascularize or medical?

Synthesises 2 trialsCREST opened the question; CREST-2 against modern medical management closed it differentially

Clinical Synthesis

In asymptomatic carotid stenosis on modern intensive medical management, carotid stenting reduces stroke vs medical therapy alone (CREST-2 2026), while endarterectomy does not; the historic CEA-vs-medical literature predates contemporary statin and antiplatelet practice and should not be relied on in 2026.

Bottom line

For asymptomatic carotid stenosis ≥70%, start intensive medical management first; in patients who would otherwise be revascularization candidates, carotid artery stenting at an experienced center is now a defensible add-on per CREST-2 (NNT 31 over 4 years), while CEA is not.

Sources

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis· 2010CREST-2· 2026§5.3 Carotid Artery Disease· 2021

Trials in this question· 2

CREST2010
Carotid stenting and endarterectomy showed no significant difference on the 4-year composite, but with different risks: more periprocedural stroke with stenting, more myocardial infarction with surgery.
No clear winner7.2% vs 6.8%
CREST-22026
Stenting beat modern intensive medical management for asymptomatic ≥70% carotid stenosis (NNT 31). Endarterectomy did not.
NNT 31 / NS CEACAS 2.8% vs 6.0% (P=0.02)

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