Abstract Number: Esoc2026a2248 Periprocedural and Long-Term Outcomes of Carotid Artery Stent Placement in Asymptomatic Patients: A Real-World Analysis

Abstract Background and aims The CREST (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis)-2 trial reported superiority of CAS (Carotid Artery Stent placement) in selected asymptomatic patients over medical treatment. We evaluated if these outcomes are reproducible in real-world U.S. practice using a "target trial emulation" approach. Methods We analyzed 2015-2025 data from the ORACLE electronic health record (EHR) database for asymptomatic patients aged ≥35 years who underwent CAS. Asymptomatic status was approximated by excluding patients with prior stroke, transient ischemic attack, amaurosis fugax, or recent stroke/unstable angina. Outcomes were similar to the CREST-2 endpoints: (1) stroke or death within 44 days; and (2) new ischemic stroke from day 44 up to 4 years. Results Among 9,050 CAS treated asymptomatic patients (age range 35–89 years), 552 experienced stroke or death (6.10%; 95% confidence interval CI, 5.62–6.61%) within 44 days, substantially higher than the CREST-2 rate (1.30%; 95% CI, 0.6–2.5). All-cause mortality and/or new ischemic stroke occurred in 132 (1.46%; 95% CI, 1.23–1.73) and 443 (4.90%; 95% CI, 4.47–5.36) of 9,050 patients, respectively. After 44 days, 281 patients experienced a new ischemic stroke (3.10%; 95% CI, 2.77–3.48), compared to 7 in CREST-2 (annual event rate 0.4%; 95% CI, 0.2–0.9). Conclusions Peri-procedural stroke and/or death rates among asymptomatic patients undergoing CAS in U.S. clinical practice were substantially higher than those observed in CREST-2, underscoring the need for focused efforts to optimize patient selection, procedural performance, and implementation of CAS in this patient population. Conflict of interest Adnan I. Qureshi, Samrat Kumar Dey, Hassan Raza, Camilo R. Gomez, Chi-Ren Shyu: Nothing to disclose.