Objective:

To assess the role of carotid artery stenting (CAS) in patients with severe asymptomatic carotid stenosis and its effectiveness alongside intensive medical therapy.

Approach:

• Study Design: CREST-2 included two parallel randomized trials comparing CAS plus intensive medical management with medical management alone, and carotid endarterectomy plus intensive medical management with medical management alone.
• Patient Management: All participants received intensive medical management targeting systolic blood pressure below 130 mm Hg, LDL cholesterol below 70 mg/dL, and control of glycemia, smoking, weight, and physical activity.

Key Findings:

• At four years, the primary outcome occurred in 2.8% of patients assigned to stenting plus medical therapy compared to 6.0% receiving medical therapy alone.
• In the endarterectomy trial, the rates were 3.7% for endarterectomy plus medical therapy and 5.3% for medical therapy alone, with no statistical significance.
• Operator experience, patient selection, and standardized procedural techniques were crucial for achieving favorable outcomes.

Limitations:

• Revascularization was performed only by well-trained, certified, and higher-volume operators, affecting generalizability.
• The statistical margin of benefit in the stenting trial was narrow.
• Medical therapy continued to evolve during the study, and trans-carotid artery revascularization was not included.

Sources:

• Baptist Health Brain & Spine Care