CREST-2 Trials (2025)
Medical Management vs Revascularization for Asymptomatic Carotid Stenosis
Two parallel, observer-blinded randomized clinical trials (Stenting + CEA)
Objective:
To determine whether adding carotid revascularization (stenting or endarterectomy) to intensive medical management provides additional benefit over medical therapy alone in patients with high-grade asymptomatic carotid stenosis.
Inclusion Criteria (2–3 lines):
Adults ≥35 years with asymptomatic high-grade carotid stenosis ≥70% (confirmed by angiography, CTA, MRA, or Doppler criteria) and no ipsilateral stroke/TIA within 180 days, with good functional status (mRS 0–1) and suitable for stenting or endarterectomy.
Population:
Across 155 centers in 5 countries
- Stenting trial: 1,245 patients
- CEA trial: 1,240 patients
All received ** intensive medical therapy**, with or without revascularization.
Follow-up: Up to 4 years
Primary Outcome:
Composite of peri-procedural stroke/death (0–44 days) + ipsilateral ischemic stroke up to 4 years
Results:
Stenting Trial
- Medical therapy: 6.0% event rate
- Stenting + medical therapy: 2.8%
- P = 0.02 (absolute difference) → Significant benefit
- Peri-procedural (0–44 days): 0 strokes/deaths vs 8 events in stenting
Endarterectomy Trial
- Medical therapy: 5.3%
- CEA + medical therapy: 3.7%
- P = 0.24 (not significant)
- Peri-procedural strokes: 3 vs 9 with CEA
Interpretation:
- Stenting + medical therapy reduced long-term stroke risk compared with medical therapy alone, despite peri-procedural risks.
- Carotid endarterectomy did not show a statistically significant benefit over medical therapy alone.
- Advancements in modern intensive medical therapy have narrowed the advantage of surgical/endovascular treatment for asymptomatic disease.
Conclusion:
For asymptomatic high-grade carotid stenosis, stenting (with optimized medical therapy) provided a statistically significant stroke-reduction benefit over intensive medical therapy alone, whereas endarterectomy did not. Optimal medical therapy remains central and may reduce the need for surgery in many patients.
Citation:
Brott TG, Howard G, Lal BK, et al. N Engl J Med. 2025; DOI: 10.1056/NEJMoa2508800