Key result
Carotid revascularization shows no clear benefit over optimal medical therapy in asymptomatic carotid stenosis.
Why the study?
Advances in medical therapy have created uncertainty about the best treatment for asymptomatic carotid artery stenosis despite prior trials favoring carotid endarterectomy.
Supports carotid stenting plus intensive medical therapy over medical therapy alone in asymptomatic high-grade stenosis; leaves open the role of endarterectomy.
Two positive randomized trials established carotid endarterectomy (CEA) as a superior treatment to medical management alone for the treatment of asymptomatic carotid artery stenosis. However, advances in medical therapy have led to an active and spirited debate about the best treatment for asymptomatic carotid stenosis. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis (CREST 2) trial aims to better define the best treatment for the average patient with severe asymptomatic carotid stenosis. Enrollment in the trial may be hampered by strong opinions on either side of the debate. It is important to realize that equipoise exists and that neither the old data on CEA nor the new data on optimal medical therapy provide a rigorous answer. The assumption that medical therapy has already been proven superior to revascularization procedures may hinder both enrollment in the trial and technical advancements in revascularization procedures.
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Heck et al. (2017) conducted a review in asymptomatic carotid artery stenosis. Carotid endarterectomy (CEA) and revascularization procedures vs. optimal medical therapy was evaluated. Clinical equipoise exists between carotid revascularization and optimal medical therapy for asymptomatic carotid stenosis, necessitating the CREST 2 trial to determine the best treatment.
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