Evaluation of Intensive Medical Therapy Alone versus Revascularization for Carotid Stenosis

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Data Quality: STRONG
Summary of  New England Journal of Medicine https://doi.org/10.1056/NEJMoa2508800 
Dr. Thomas G. Brott  et al.

Points

The CREST-2 study enrolled over two thousand patients to compare revascularization techniques against medical therapy alone for the management of high-grade asymptomatic carotid stenosis.
Results from the stenting trial demonstrated a significant reduction in four-year stroke risk to 2.8 percent compared to 6.0 percent in the medical management group.
Analysis of the endarterectomy cohort revealed no statistically significant benefit of surgery over intensive medical therapy with a P value of 0.24 for the absolute difference.
Both interventional groups experienced higher event rates during the initial forty-four days compared to the medical therapy groups which saw minimal immediate complications.
The findings suggest stenting is the superior preventive intervention for this specific patient population while endarterectomy offers no added value over medication.

Summary

The CREST-2 program comprised two parallel, randomized, observer-blinded clinical trials investigating the efficacy of revascularization combined with intensive medical management versus medical management alone for asymptomatic high-grade (≥70%) carotid stenosis. Conducted across 155 centers, the study enrolled 1,245 patients in the stenting trial and 1,240 in the endarterectomy trial. The primary outcome measured a composite of stroke or death within 44 days of randomization or ipsilateral ischemic stroke over a four-year follow-up period.

In the stenting trial, the addition of the procedure significantly lowered the four-year incidence of primary-outcome events to 2.8% (95% CI, 1.5 to 4.3), compared to 6.0% (95% CI, 3.8 to 8.3) in the medical-therapy-only group (P=0.02). Notably, the immediate perioperative period (day 0 to 44) saw seven strokes and one death in the stenting group, while the medical-therapy group experienced no events during this specific window, though the long-term benefit favored intervention.

Conversely, the endarterectomy trial failed to demonstrate a significant clinical advantage. The four-year incidence of primary events was 3.7% (95% CI, 2.1 to 5.5) for the surgical group versus 5.3% (95% CI, 3.3 to 7.4) for the medical-therapy group (P=0.24). These findings indicate that while carotid artery stenting offers a statistically significant reduction in long-term stroke risk for asymptomatic patients when paired with medical therapy, carotid endarterectomy provides no such benefit over medication alone.

Link to the article: https://www.nejm.org/doi/10.1056/NEJMoa2508800

References

Brott, T. G., Howard, G., Lal, B. K., Voeks, J. H., Turan, T. N., Roubin, G. S., Lazar, R. M., Brown, R. D., Huston, J., Edwards, L. J., Jones, M., Clark, W. M., Chamorro, Á., Llull, L., Mena-Hurtado, C., Heck, D., Marshall, R. S., Howard, V. J., Moore, W. S., … Meschia, J. F. (2025). Medical management and revascularization for asymptomatic carotid stenosis. New England Journal of Medicine, NEJMoa2508800. https://doi.org/10.1056/NEJMoa2508800