Among patients with asymptomatic carotid artery stenosis (CAS), the addition of stenting to medical therapy led to a significantly lower risk of stroke compared with medical therapy alone, whereas endarterectomy failed to provide a significant benefit, according to two parallel CREST-2 trials presented at the Society of Vascular and Interventional Neurology meeting and published simultaneously Nov. 21 in NEJM.

Thomas G. Brott, MD, et al., conducted two trials involving patients with high-grade (≥70%) CAS seen in 155 centers in five countries. All patients were receiving intensive medical therapy and were randomized to either transfemoral carotid artery stenting (n=1,245; mean age, 69 years; 38% women) or carotid endarterectomy (n=1,240; mean age, 70 years; 37% women). Both groups were compared with patients receiving intensive medical management alone.

Results showed that the primary outcome, a composite of any stroke or death within the first 44 days or ipsilateral ischemic stroke within four years, occurred in 6.0% of patients treated with medical therapy alone and 2.8% of those who underwent stenting (p=0.02), showing a significant benefit with stenting. In contrast, the respective primary outcome in the endarterectomy trial was 5.3% in the medical therapy alone group and 3.7% in the endarterectomy group (p=0.24), showing no significant between-group difference.

Findings in the stenting trial for days 0-44 revealed no strokes or deaths in the medical therapy group compared with seven strokes and one death observed in the stenting group (1.3%). After 44 days, the annual rate of ipsilateral ischemic stroke was 1.7% among patients in the medical therapy alone group and 0.4% in the stenting group.

For the endarterectomy trial for days 0-44, findings revealed no deaths occurred; however, three strokes occurred in the medical therapy group (0.5%) vs. nine strokes in the endarterectomy group (1.5%). After 44 days, the annual rate of ipsilateral ischemic stroke was 1.3% in the medical therapy group and 0.5% in the endarterectomy group.

In an accompanying editorial comment, Martin M. Brown, FRCP, and Leo H. Bonati, MD, note that the CREST-2 endarterectomy trial findings had similar results to the SPACE-2 and ECST-2 trials and "conclude that there is no longer a role for routine carotid endarterectomy in persons with asymptomatic stenosis." As for stenting, they express caution for several reasons, including the small absolute difference between stenting and medical treatment alone and suggest advising these patients "to start intensive medical therapy immediately and to delay revascularization until ... symptoms develop."