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.

Interpretation:

The results of the CREST-2 trial suggest that CAS in conjunction with intensive medical therapy may provide a significant reduction in the risk of major vascular events compared to medical therapy alone in patients with severe asymptomatic carotid stenosis. The findings highlight the importance of comprehensive medical management in conjunction with procedural interventions.

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.

Conclusion:

The CREST-2 trial underscores the evolving role of CAS in the management of severe asymptomatic carotid stenosis, indicating that it may be a beneficial option when combined with intensive medical therapy, although careful consideration of operator experience and patient selection remains essential for optimizing outcomes.