Revascularization Plus Medical Therapy Versus Medical Therapy Alone for Asymptomatic Carotid Stenosis: A Meta‐Analysis

BACKGROUND: Management of asymptomatic carotid stenosis (ACS) remains controversial, particularly as contemporary optimal medical therapy (OMT) has evolved beyond the aspirin-based regimens used in earlier trials. We performed a meta-analysis comparing carotid revascularization plus OMT versus OMT alone in patients with ACS. METHODS: We searched five databases (PubMed, Embase, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials [CENTRAL]) from inception to November 2025. Randomized controlled trials comparing carotid revascularization (endarterectomy or stenting) plus OMT versus OMT alone were included. Primary outcomes were 30- to 44-day mortality and stroke. Other outcomes included long-term all-cause mortality, stroke, myocardial infarction, and intracerebral hemorrhage. All statistical analyses were performed in R, and risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using either fixed- or random-effects models. RESULTS: Six trials involving 8276 patients were included. Revascularization significantly increased 30- to 44-day mortality (RR 3.98 [95% CI, 1.53-10.35], p = 0.0046) and stroke risk (RR 4.53 [95% CI, 2.51-8.17], p < 0.0001). However, long-term follow-up demonstrated significant reductions in all-cause mortality (RR 0.80 [95% CI, 0.68-0.93], p = 0.0053) and stroke (RR 0.66 [95% CI, 0.57-0.76], p < 0.0001). No significant differences were observed in myocardial infarction or intracerebral hemorrhage rates. CONCLUSIONS: Carotid revascularization combined with OMT was associated with increased periprocedural risks but lower long-term stroke and mortality in pooled analyses of patients with ACS. These findings should be interpreted cautiously given differences across trials and evolving OMT standards. Patient selection should balance procedural risks against potential long-term benefit, particularly among patients with high-grade stenosis, low periprocedural risk, and access to experienced centers.