Stenting reduced strokes in asymptomatic stenosis
For severe carotid narrowing without recent symptoms, adding carotid-artery stenting to intensive medical management reduced stroke or death over 4 years, while surgery did not.
*Two parallel randomized controlled trials; Level 1b (OCEBM).

Citation

Brott TG, Howard G, Lal BK, et al.; CREST-2 Investigators. Medical Management and Revascularization for Asymptomatic Carotid Stenosis. N Engl J Med. 2026;394:219-231. doi:10.1056/NEJMoa2508800.

Background

Older trials favored carotid surgery for preventing stroke in people without symptoms, but modern medicines and newer procedures may have changed the balance of benefits and harms. This study tested whether adding a procedure to intensive medical management improves outcomes.

Patients

Adults ≥35 years with severe (≥70%) carotid-artery narrowing and no recent stroke-like symptoms (within 180 days), at 155 centers in 5 countries.

Intervention

(1) Carotid-artery stenting plus intensive medical management; (2) carotid endarterectomy plus intensive medical management.

Control

Intensive medical management alone.

Outcome

Primary: any stroke or death through day 44, or later stroke on the treated side through 4 years.

Follow-up Period

Up to 4 years (median 3.6 years in the stenting trial; 4.0 years in the surgery trial).

Results

Significant outcome Medical management alone Procedure + medical management Effect
Primary composite at 4 years (stenting trial) 6.0% 2.8% Risk ratio 2.13 (95% CI, 1.15–4.39); absolute reduction 3.2%; NNT≈32 over 4 years
Stroke on treated side after day 44 (stenting trial; annual rate) 1.7% per year 0.4% per year Risk ratio 4.07 (95% CI, 1.78–9.31)
Stroke on treated side after day 44 (surgery trial; annual rate) 1.3% per year 0.5% per year Risk ratio 2.38 (95% CI, 1.13–5.00)
Early (first 44 days) stroke or death events were uncommon but occurred more often in the procedure groups.
Primary analyses were intention-to-treat.

Limitations

Patients and clinicians were not blinded; medical treatment targets changed during the long trial; procedures done by highly certified operators; crossovers; few total events made results sensitive to small changes.

Funding

National Institutes of Health; U.S. Medicare agency; Regeneron donated medication.

Clinical Application

In severe asymptomatic carotid narrowing, prioritize intensive medical management; consider stenting (in experienced centers) for selected patients, but routine surgery is not clearly beneficial.