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 carotid endarterectomy did not lead to a significant benefit in the parallel endarterectomy trial (3.7% vs 5.3%, P=0.24); 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 carotid endarterectomy did not separate from intensive medical management in the parallel trial (3.7% vs 5.3%, P=0.24), so routine CEA in this setting is no longer supported by RCT-level evidence.
Trials in this question· 2
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