CREST-2 Trial Explained (Carotid Stenosis Treatment)

Show notes

🎙️ CREST-2 Results—A New Role for Carotid Stenting
This episode unpacks the long-awaited results of the CREST-2 Trial, a landmark study published in the New England Journal of Medicine (November 2025) that reshapes how we think about treating asymptomatic carotid stenosis (narrowing of the carotid artery without recent stroke symptoms).

The Big Question: Does adding invasive revascularization (Endarterectomy or Stenting) to Intensive Medical Management (IMM) prevent more strokes than medication and lifestyle changes alone?

The Verdict: After full enrollment and ~4 years of follow-up, the two parallel trials gave different answers for the two procedures:

• Carotid Artery Stenting (CAS): adding CAS to IMM significantly reduced stroke/death — 2.8% in the CAS + IMM group versus 6% with IMM alone at 4 years (absolute risk reduction 3.2%, statistically significant). Post-procedural stroke risk was reduced by ~75%.

• Carotid Endarterectomy (CEA): adding CEA to IMM did NOT show a significant additional benefit over medical management alone.

The Power of Medical Therapy: Modern intensive medical management—including tight blood pressure control (target <130/80) and high-intensity statins—remains highly effective. For patients unsuitable for stenting, IMM alone is a reasonable strategy, and CEA no longer adds a clear benefit on top.

The Procedure Gap: CAS and CEA now have divergent roles in asymptomatic disease. CAS + IMM is favored where anatomy and operator experience permit; CEA + IMM has lost its historical edge.

Source: Howard VJ et al., CREST-2 Investigators. NEJM, Nov 21, 2025.