Key result
Review summarizes CREST-2 results comparing carotid endarterectomy or stenting to medical therapy for asymptomatic stenosis.
Why the study?
Improvements in contemporary medical therapy may have negated carotid endarterectomy benefits in asymptomatic carotid stenosis, and large trials comparing stenting with modern medical treatment were lacking.
Does carotid endarterectomy or stenting improve outcomes compared to modern medical treatment in patients with asymptomatic carotid stenosis?
Does carotid endarterectomy or stenting improve outcomes compared to modern medical treatment in patients with asymptomatic carotid stenosis?
This paper provides an interpretation of the CREST-2 trial results to guide clinical practice regarding the choice between revascularization and modern medical therapy for asymptomatic carotid stenosis.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“On first impression, the results suggest that CAS should be preferred over medical therapy alone, and CEA confers no added benefit. However, we suggest that the CREST-2 findings are interpreted with caution before widespread application to clinical practice.”
“Based on the available evidence, and considering patient preference, we suggest that the following pragmatic approach is reasonable in practice. We suggest that intensive medical therapy combined with lifestyle optimization (particularly smoking cessation) be considered initially, with advice to seek immediate medical attention in the unlikely event that symptoms of transient ischemic attack or stroke occur.”
“Although internally valid for the patients involved in CREST-2, the selection of expert operators is likely to limit the external validity of the trial in unselected clinical settings. The observed low periprocedural complication rates emphasize the need for similar quality control measures in routine clinical practice.”
Supports stenting plus intensive medical therapy for asymptomatic ≥70% stenosis; extends prior trials by demonstrating benefit over contemporary medical management.
Older randomized trials have shown modest benefit for carotid endarterectomy for selected patients with asymptomatic carotid stenosis compared with medical treatment. However, improvements in contemporary medical therapy may have negated the benefit of carotid endarterectomy, and no large randomized trials comparing stenting with modern medical treatment have been completed. The recently reported CREST-2 trial addressed these evidence gaps. We describe the main results of CREST-2 and our interpretation of the findings for clinical practice.
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Kelly et al. (2026) conducted a review in Asymptomatic carotid stenosis. Carotid endarterectomy or stenting vs. Modern medical treatment was evaluated. This article reviews the main results and clinical interpretation of the CREST-2 trial comparing carotid endarterectomy or stenting with modern medical therapy for asymptomatic carotid stenosis.
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