Carotid Artery Stenosis: What to Choose — Stenting, Endarterectomy, or Medication Therapy? The Differences Are Now Clear
Igor Vyacheslavovich Pershukov is a professor, Doctor of Medical Sciences, and also a PhD, heading the Department of Hospital Therapy with a course in Radiological Diagnostics and Oncology at Jalal-Abad State University.
In his comments, he notes: “On January 15, 2026, the oldest medical journal – The New England Journal of Medicine, published by the Massachusetts Medical Society (USA), released new data on the outcomes of stenting, endarterectomy, and pharmacotherapy for asymptomatic significant carotid artery stenosis exceeding 70%.
The question of treating asymptomatic carotid artery stenosis, which does not manifest symptoms, has long remained open. Research that began over thirty years ago showed only minimal advantages of carotid endarterectomy compared to pharmacotherapy; however, advancements in medical stroke prevention call into question the effectiveness of this method. While stenting of the carotid artery has become less invasive, it has remained a somewhat unjustified alternative to endarterectomy for treating asymptomatic stenosis.
As part of the CREST-2 study, the results of which were published in The New England Journal of Medicine, a parallel comparison of stenting with pharmacotherapy and carotid endarterectomy with pharmacotherapy was conducted.
Participants in the study "Revascularization of Carotid Arteries and Pharmacological Treatment of Asymptomatic Carotid Artery Stenosis" (CREST-2) provided important data that could clarify this issue.
The study included two parallel protocols, in which all patients underwent intensive pharmacotherapy. The first study, involving 1,245 patients randomly assigned to stenting and pharmacotherapy only, showed significant advantages for stenting. At the same time, the second study, in which 1,240 patients were assigned to carotid endarterectomy and pharmacotherapy only, did not reveal significant differences between these groups.
Key findings of the study: The graph shows Kaplan-Meier estimates of the frequency of primary outcomes over 4 years in the stenting and endarterectomy groups. The primary outcome was any stroke or death assessed from randomization to 44 days, or ipsilateral ischemic stroke assessed during the remaining time up to 4 years.
How can the obtained results be interpreted? They align with the data from two other recent studies concerning similar issues: SPACE-2 and ECST-2. These data allow us to conclude that routine carotid endarterectomy for asymptomatic stenosis is no longer necessary.
Based on the results of CREST-2, the question arises: should stenting be widely applied in asymptomatic stenosis? Experts caution against hasty conclusions. First, the low stroke rate with stenting is associated with careful patient selection and high qualifications of specialists, which are not always available in vascular centers. Previously conducted studies, such as ACST-2, which included 3,625 patients, showed that the rate of periprocedural stroke or death with stenting was slightly higher than with endarterectomy.
Secondly, the difference between stenting and pharmacotherapy was based on a small number of events; if there had been three more cases in the stenting group, the difference would have been insignificant. In the SPACE-2 study, where only 197 patients were assigned to stenting, the advantages of this method over pharmacotherapy were not found. Analyzing the overall event rates in the four groups of CREST-2, there are more similarities than differences between endarterectomy and stenting. Most importantly, the benefit of revascularization for asymptomatic stenosis in preventing stroke has become negligible due to improvements in pharmacotherapy.
Thirdly, pharmacotherapy can be further improved, as the authors acknowledge. During the follow-up in CREST-2, only 60-70% of patients achieved the target systolic blood pressure level (<130 mmHg), less than 80% of patients had low-density lipoprotein (LDL) cholesterol levels below 70 mg/dL (<1.80 mmol/L), and about 50% of diabetic patients reached the target level of glycated hemoglobin. New drugs, such as PCSK9 inhibitors, as well as lower target LDL levels below 55 mg/dL (<1.40 mmol/L) provide treatment opportunities that were not available within the CREST-2 study.
Proportion of patients with target systolic pressure in the stenting study
Proportion of patients with target systolic pressure in the endarterectomy study
Proportion of patients achieving target LDL cholesterol levels in the stenting study
Proportion of patients achieving target LDL cholesterol levels in the endarterectomy study
The question of whether the observed benefit over 4 years justifies the early risks associated with stenting is also important. In CREST-2, the rate of periprocedural stroke or death with stenting was 1.3%, while there were no such complications with pharmacotherapy. Later, the rate of ipsilateral stroke was 0.4% per person per year in the stenting group compared to 1.7% per person per year in the pharmacotherapy group. Thus, among 100 patients who underwent stenting, only one per year would gain real benefit from stroke prevention, while one patient could suffer a stroke or die as a result of the procedure.
Over 4 years, 95 out of 100 patients underwent an unnecessary procedure. It is important to note that about two-thirds of complications in patients receiving only pharmacotherapy were non-disabling strokes, which usually lead to good or satisfactory recovery. In this case, revascularization is indicated for treating symptomatic carotid artery stenosis. Therefore, experts recommend starting intensive pharmacotherapy in patients with asymptomatic stenosis and postponing revascularization until symptoms appear, which will occur only in a small group of patients. Exceptions may be made for those who prefer to risk revascularization or cannot take medications – for such patients, stenting may be the best option if qualified interventional cardiologists are available.
The researchers of CREST-2 deserve congratulations for conducting a large-scale study dedicated to the treatment of asymptomatic carotid artery stenosis using intensive pharmacotherapy. The world now needs studies aimed at identifying the small number of patients with stenosis who develop symptoms despite pharmacotherapy. A promising approach is the use of magnetic resonance imaging of atherosclerotic plaques in the carotid artery to detect intraplaque hemorrhage, which is a strong predictor of stroke.”
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