Medical management vs revascularization for asymptomatic carotid stenosis: contemporary bayesian network meta-analysis of randomized controlled Trials

Background The optimal management of asymptomatic carotid artery stenosis remains uncertain in the era of contemporary intensive medical therapy (MT) and evolving carotid revascularisation techniques. Purpose To compare the effectiveness and safety of carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and MT alone in patients with asymptomatic carotid artery stenosis using a contemporary Bayesian network meta-analysis of randomised controlled trials (RCTs). Methods We performed a systematic review and Bayesian network meta-analysis of RCTs comparing CEA, TFCAS, and MT in adults with asymptomatic carotid stenosis. PubMed and Embase were searched from inception to 28 January 2026, complemented by registry and citation screening. This systematic review and network meta-analysis followed a prespecified protocol registered in PROSPERO and was reported in accordance with PRISMA. Random-effects Bayesian models were used to estimate odds ratios (ORs) with 95% credible intervals (CrIs). The primary effectiveness outcome was a composite of periprocedural stroke or death and ipsilateral ischaemic stroke during follow-up. The primary safety outcome was periprocedural stroke or death within 30 days. Exploratory time-dependent analyses assessed cumulative risk trajectories. Results Ten contemporary RCTs including 9,800 patients were analysed. CEA was associated with lower odds of the primary effectiveness outcome compared with MT (3.5% vs 4.5%; OR 0.60, 95% CrI 0.36–0.98), whereas TFCAS was not (OR 0.76, 95% CrI 0.39–1.35). Both CEA (2.2% vs 0.2%; OR 11.84, 95% CrI 3.74–37.51) and TFCAS (2.8% vs 0.2%; OR 15.47, 95% CrI 4.91–48.69) were associated with higher odds of the primary safety outcome versus MT. Time-dependent modelling suggested that early procedural risk with revascularisation was progressively offset by lower subsequent stroke risk versus MT. The estimated break-even time at which cumulative risk became lower than MT was 2.5 years for CEA (95% uncertainty interval 0.9–3.7) and 3.4 years for TFCAS (95% uncertainty interval 1.2–4.8). Conclusions In contemporary RCTs of asymptomatic carotid stenosis, CEA was associated with improved long-term effectiveness compared with MT, whereas TFCAS was not. Both revascularisation strategies carried higher early procedural risk that appeared progressively offset over time by stroke prevention. These findings may inform patient selection and shared decision-making in the modern medical therapy era.