[Evidence-based treatment of patients with asymptomatic carotid stenosis - a comment on the CREST-2 trial]

The CREST-2 trial randomized 2,485 well-selected low-risk patients with asymptomatic ≥70% carotid stenosis to best medical treatment (BMT) alone versus revascularization. Carotid endarterectomy (CEA) plus BMT showed no benefit over BMT alone (3.7% vs 5.3% primary endpoint at 4 years, p=0.24). Carotid Artery Stenting (CAS) plus BMT significantly reduced the endpoint compared to BMT alone (2.8% vs 6.0%, p=0.02), but the difference was fragile and peri-procedural risk was exceptionally low (1.3-1.5%) due to highly selected patients and expert operators. Many high-risk features were excluded, and BMT targets were often missed in all four groups. Conclusion: optimal medical therapy remains the cornerstone and is sufficient for most patients. CAS may be considered for carefully selected, motivated patients with favorable anatomy, when performed in high-volume centers with low complication rates using modern endovascular techniques.