Medical Management and Revascularization for Asymptomatic Carotid Stenosis.
Publication/Presentation Date
1-15-2026
Abstract
BACKGROUND: Improvements in medical therapy, carotid-artery stenting, and carotid endarterectomy call into question the preferred management of asymptomatic carotid stenosis. Whether adding revascularization to intensive medical management would provide greater benefit than intensive medical management alone is unclear.
METHODS: We conducted two parallel, observer-blinded clinical trials that enrolled patients with high-grade (≥70%) asymptomatic carotid stenosis across 155 centers in five countries. The stenting trial compared intensive medical management alone (medical-therapy group) with carotid-artery stenting plus intensive medical management (stenting group); the endarterectomy trial compared intensive medical management alone (medical-therapy group) with carotid endarterectomy plus intensive medical management (endarterectomy group). The primary outcome was a composite of any stroke or death, assessed from randomization to 44 days, or ipsilateral ischemic stroke, assessed during the remaining follow-up period up to 4 years.
RESULTS: A total of 1245 patients underwent randomization in the stenting trial and 1240 in the endarterectomy trial. In the stenting trial, the 4-year incidence of primary-outcome events was 6.0% (95% confidence interval [CI], 3.8 to 8.3) in the medical-therapy group and 2.8% (95% CI, 1.5 to 4.3) in the stenting group (P = 0.02 for the absolute difference). In the endarterectomy trial, the 4-year incidence of primary-outcome events was 5.3% (95% CI, 3.3 to 7.4) in the medical-therapy group and 3.7% (95% CI, 2.1 to 5.5) in the endarterectomy group (P = 0.24 for the absolute difference). From day 0 to 44, in the stenting trial, no strokes or deaths occurred in the medical-therapy group and seven strokes and one death occurred in the stenting group; in the endarterectomy trial, three strokes occurred in the medical-therapy group and nine strokes occurred in the endarterectomy group.
CONCLUSIONS: 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. (Funded by the National Institute of Neurological Disorders and Stroke and others; CREST-2 ClinicalTrials.gov number, NCT02089217.).
Volume
394
Issue
3
First Page
219
Last Page
231
ISSN
1533-4406
Published In/Presented At
Brott, T. G., Howard, G., Lal, B. K., Voeks, J. H., Turan, T. N., Roubin, G. S., Lazar, R. M., Brown, R. D., Jr, Huston, J., 3rd, Edwards, L. J., Jones, M., Clark, W. M., Chamorro, Á., Llull, L., Mena-Hurtado, C., Heck, D., Marshall, R. S., Howard, V. J., Moore, W. S., Barrett, K. M., … CREST-2 Investigators (2026). Medical Management and Revascularization for Asymptomatic Carotid Stenosis. The New England journal of medicine, 394(3), 219–231. https://doi.org/10.1056/NEJMoa2508800
Disciplines
Business Administration, Management, and Operations | Health and Medical Administration | Management Sciences and Quantitative Methods
PubMedID
41269206
Department(s)
Administration and Leadership
Document Type
Article