Carotid Artery Stenting: Evolution, Evidence, and Contemporary Practice in the Era of Intensive Medical Therapy

Carotid artery stenosis remains a major cause of ischemic stroke worldwide, and its management continues to evolve in parallel with advances in surgical, endovascular, and medical therapies. Carotid endarterectomy (CEA) was established as the standard of care for symptomatic high-grade stenosis following landmark randomized trials, while carotid artery stenting (CAS) subsequently emerged as a less invasive alternative for appropriately selected patients. This review aims to summarize the historical evolution of carotid artery stenting, critically appraise evidence from major clinical trials comparing CAS and CEA, and examine contemporary practice patterns in the era of intensive medical therapy. A comprehensive review of randomized trials, registries, guideline statements, and recent literature was performed to synthesize current evidence regarding procedural outcomes, patient selection, and emerging technologies, including transcarotid artery revascularization (TCAR). Large, randomized trials have demonstrated comparable long-term composite outcomes between CAS and CEA in selected patients, although peri-procedural risk profiles differ, with higher stroke risk observed after CAS and higher myocardial infarction rates after CEA. Technological advancements in embolic protection devices, stent platforms, and alternative access strategies have further refined endovascular approaches. Concurrently, improvements in intensive medical therapy-including lipid-lowering, antiplatelet therapy, blood pressure control, smoking cessation, and lifestyle modification-have substantially reduced overall stroke risk, particularly in asymptomatic patients. In the contemporary era, optimal stroke prevention requires individualized, multidisciplinary decision-making that integrates symptom status, anatomical complexity, comorbid conditions, procedural expertise, and sustained long-term vascular risk factor management following revascularization.