CREST-2: Early reflections on the primary results

The CREST-2 trial was designed to clarify the contemporary role of carotid revascularization in the management of high-grade asymptomatic carotid stenosis in the setting of increasingly effective medical therapy. Trial execution occurred during a period of rapid evolution in risk-factor management and device technology, raising important questions about how changes in standards of care should influence stroke-prevention strategies. Participants received protocol-driven intensive medical management focused on stringent control of systolic blood pressure and low-density lipoprotein, with adjustments made as guidelines evolved. In the stenting arm, CREST-2 applied rigorous credentialing to ensure procedural expertise. Enrollment was restricted to patients with favorable vascular anatomy and lesion characteristics. Many participants entered the trial with opportunities to improve key vascular risk factors. Obesity and overweight were common among the cohort, and although new weight-loss agents may modify cardiovascular risk profiles, their effects on carotid atherosclerosis remain uncertain. With stringent operator credentialing and selective anatomical eligibility, carotid stenting demonstrated improved periprocedural safety relative to earlier multicenter experiences and effective stroke prevention. Carotid endarterectomy continued to show numerically favorable stroke-prevention outcomes compared with intensive medical management alone, although the observed risk reduction at 4 years did not reach statistical significance. Intensive medical management remains the foundational treatment strategy, yet revascularization retains an important role when performed by experienced operators in appropriately selected patients.