Controversies in the management of asymptomatic carotid stenosis: from best medical therapy to a redefinition of surgical indications

Asymptomatic carotid artery stenosis has become increasingly detected with population aging and the widespread use of high-resolution vascular imaging. Its management is undergoing a transition from stenosis-based anatomical assessment toward multidimensional biological risk stratification. The relative benefit of prophylactic carotid revascularization, including carotid endarterectomy and carotid artery stenting, versus best medical therapy remains controversial. In recent years, best medical therapy has evolved substantially with intensive lipid-lowering strategies, PCSK9 inhibitors, novel glucose-lowering agents, and improved control of vascular risk factors, thereby reshaping the expected benefit of preventive intervention. Meanwhile, recent randomized trials, including ACST-2, ECST-2, and CREST-2, have challenged the traditional reliance on luminal stenosis as the dominant criterion for intervention. This review summarizes key evidence from 2021 to 2026 regarding contemporary medical therapy, revascularization trials, and emerging approaches to risk assessment in asymptomatic carotid stenosis. It discusses the clinical value of high-resolution magnetic resonance imaging, cerebrovascular hemodynamic reserve, and exosomal microRNAs for identifying vulnerable plaques and biologically high-risk disease. It also reconsiders the definition of "asymptomatic" by incorporating covert cognitive impairment and findings from CREST-H. Finally, this review proposes an individualized precision-management framework based on multimodal biomarkers.