Endovascular TodayCREST-2 Shows Reduced Stroke Risk with Carotid Artery Stenting Plus Intensive Medical Management; No Added Benefit Seen with CEA

CREST-2 trials found carotid artery stenting plus intensive medical therapy cut stroke risk by more than half versus medical therapy alone in asymptomatic high-grade carotid stenosis—while carotid endarterectomy showed no significant benefit. Study enrolled 2,485 patients across 155 centers with 4-year follow-up.

🔬 CLINICAL CONSIDERATIONS

• CAS reduced 4-year stroke/death rates from 6.0% to 2.8% (number needed to treat = 31), with fourfold risk reduction post-procedure
• CEA failed to show significant benefit (5.3% vs 3.7%, P=.24) despite historical support for surgical intervention in this population
• Intensive medical management achieved target BP/lipid control in 70%+ patients, establishing new baseline for asymptomatic stenosis outcomes with modern therapy
• Periprocedural stroke rates remained low across all groups when performed by experienced operators (< 3% complication threshold required)

💊 PRACTICE APPLICATIONS

• Prioritize CAS over CEA for suitable anatomy with experienced operators for asymptomatic stenosis
• Implement intensive medical management protocols targeting BP < 130 mmHg, LDL < 70 mg/dL
• Refer to high-volume centers meeting < 3% periprocedural stroke/death rate threshold
• Counsel patients that medical therapy alone carries 4x higher long-term stroke risk vs stenting

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