Igor Vladimirovich Pershukov is a professor, Doctor of Medical Sciences, and PhD, heading the Department of Hospital Therapy with a course in Radiological Diagnostics and Oncology at Jalal-Abad State University.
Here are his words:
“The esteemed medical journal – The New England Journal of Medicine, founded in 1812 and published by the Massachusetts Medical Society (USA), presented new data on the outcomes of stenting, endarterectomy, and purely medical therapy for asymptomatic carotid artery stenosis with a severity of over 70% on January 15, 2026.
Treatment of asymptomatic carotid artery stenosis has previously sparked much debate. Studies that began over three decades ago indicated slight advantages of carotid endarterectomy compared to medical therapy; however, modern successes in stroke prevention call its necessity into question. At the same time, stenting, although less invasive, remained an alternative lacking sufficient evidence for its use in asymptomatic stenosis.
In the CREST-2 study, the results of which were published in The New England Journal of Medicine, stenting was compared with medical treatment and endarterectomy with medical treatment in a parallel independent analysis.
Participants in the "Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis" (CREST-2) study provided valuable data to illuminate these issues.
Within the CREST-2 study, two parallel studies were conducted, in which all patients received intensive medical treatment. In one of them, 1245 participants were randomly assigned to undergo stenting or only medical treatment, showing clear advantages for stenting. In the other study, where 1240 patients underwent carotid endarterectomy or only medical therapy, no significant differences were found.
Key findings of the study: The graph shows Kaplan-Meier estimates of primary outcome rates over 4 years in the stenting and endarterectomy studies. The primary outcome was any stroke or death, assessed from randomization to 44 days, or ipsilateral ischemic stroke, assessed over the remaining follow-up period up to 4 years.
How should these results be evaluated? The data from the CREST-2 endarterectomy study are consistent with the results of two recent smaller studies also addressing similar questions: SPACE-2 and ECST-2. This leads to the conclusion that routine carotid endarterectomy for asymptomatic stenosis is no longer necessary.
However, do the conclusions of CREST-2 mean that stenting should be widely used for asymptomatic stenosis? Experts are divided. Firstly, the low stroke rate with stenting is associated with careful patient selection and a high level of interventionalist qualification, which is not always available in vascular centers. Previously conducted studies comparing stenting and endarterectomy for asymptomatic stenosis, including ACST-2, showed that the risk of periprocedural stroke or death with stenting is 1 percentage point higher than with endarterectomy.
Secondly, the difference between stenting and medical treatment is based on a small number of cases; the authors note that if three additional cases had occurred in the stenting group, the differences would have been insignificant. The SPACE-2 study, which involved 197 patients, did not demonstrate advantages of stenting over optimal medical therapy. Analyzing the overall event rate among all four patient groups in CREST-2, there are more similarities than differences between stenting and endarterectomy. More importantly, the benefit of revascularization for asymptomatic carotid artery stenosis in the context of stroke prevention has become negligible due to improvements in medical therapy.
Thirdly, medical therapy can be further intensified, as the authors acknowledge. During follow-up in CREST-2, only 60-70% of patients achieved the target systolic blood pressure level (<130 mm Hg), less than 80% achieved the target LDL cholesterol level of less than 70 mg/dL (less than 1.80 mmol/L), and only about 50% of diabetic patients had a hemoglobin A1c level within the target range. New lipid-lowering drugs, such as PCSK9 inhibitors, and lower target levels of LDL cholesterol of less than 55 mg/dL (less than 1.40 mmol/L) open new treatment possibilities that were not available in the CREST-2 study.
Proportion of patients in the stenting study who achieved target systolic pressure
Proportion of patients in the endarterectomy study who achieved target systolic pressure
Proportion of patients achieving target LDL cholesterol levels in the stenting study
Proportion of patients achieving target LDL cholesterol levels in the endarterectomy study
Another important question is whether the observed benefit over the 4-year study period justifies the increased risk associated with stenting. In CREST-2, the rate of periprocedural stroke or death with stenting was 1.3%, while with medical therapy alone, no complications were observed. In subsequent stages, the rate of ipsilateral stroke was 0.4% per person per year in the stenting group and 1.7% in the medical therapy group. Thus, out of 100 patients who underwent stenting, only about 1 receives a real benefit from stroke prevention, while approximately 1 patient will face a stroke or death as a result of the procedure.
Over 4 years, 95 out of 100 patients underwent an unnecessary procedure. It is also worth noting that about two-thirds of complications in patients receiving only medical treatment were non-disabling strokes. Generally, they recover well or satisfactorily, and in such cases, revascularization is indicated for symptomatic carotid artery stenosis. Therefore, experts recommend that patients with asymptomatic carotid artery stenosis immediately begin intensive medical therapy and postpone revascularization until symptoms appear, which occurs in only a small portion of patients. Exceptions will be made for those willing to take the risk of revascularization or who cannot take medications – for them, stenting will be the preferred option in centers with highly qualified interventional cardiologists.
Researchers of CREST-2 should be commended for conducting a large-scale study dedicated to the treatment of asymptomatic carotid artery stenosis against the backdrop of intensive medical therapy. The world currently needs studies aimed at identifying a small group of patients with stenosis who continue to develop symptoms despite medical therapy. A promising approach may be the use of magnetic resonance imaging to detect intra-arterial hemorrhages, which are a significant risk factor for stroke.”
