Optimal Medical Therapy, Stenting, or Endarterectomy for Asymptomatic Carotid Stenosis

Objectives: Contemporary optimal medical therapy (OMT) has substantially improved outcomes in patients with asymptomatic carotid artery stenosis. However, the comparative effectiveness of OMT alone, carotid artery stenting (CAS), and carotid endarterectomy (CEA) remains uncertain after recent randomized trials. Methods: MEDLINE, EMBASE, and CENTRAL were searched through January 2026 to identify studies reporting the long-term outcomes following CEA, CAS, or OMT. The primary outcome was a composite of any stroke or death during the periprocedural period or ipsilateral ischemic stroke during the remaining follow-up. The secondary outcomes included periprocedural death or stroke, and postprocedural ipsilateral stroke during follow-up. A random-effects network meta-analysis was conducted to compare the outcomes. Reconstructed time-to-event data from Kaplan-Meier curves were pooled, and landmark analyses were performed to assess time-varying treatment effects and delineate the net benefits of CAS or CEA compared with OMT. We excluded studies conducted earlier than 2000 to reflect contemporary practice. Results: Seven RCTs involving 9,257 patients (CAS, n = 4,307; CEA, n = 3,585; OMT, n = 1,365) were analyzed for the primary outcome, with a median follow-up of 45 months. Compared with OMT, CEA was associated with a lower risk of the primary outcome (hazard ratio [HR] 0.59; 95% CI 0.40-0.89), whereas CAS did not demonstrate a statistically significant difference (HR 0.78; 95% CI 0.52-1.16). CAS was associated with a higher risk of the primary endpoint compared with CEA (HR 1.31; 95% CI 1.03-1.67), largely driven by periprocedural death or stroke. Periprocedural events occurred in 1.97% (95% CI 1.41-2.73) of patients undergoing CEA and 2.62% (95% CI 1.95-3.51) of those undergoing CAS. In a landmark analysis beyond the periprocedural period, both CEA and CAS were effective in reducing stroke risk compared with OMT. Conclusion: Among patients with asymptomatic carotid stenosis, CEA was associated with a lower risk of a composite of perioperative stroke or death or ipsilateral stroke during follow-up than OMT alone or CAS. The net benefit of CAS compared to OMT depends on minimizing periprocedural events rate, underscoring the importance of patient selection and procedural expertise.