The long-awaited results of the CREST-2 trials were published in The New England Journal of Medicine on November 21, 2025. These data provide important new evidence on the management of asymptomatic high-grade (≥70%) carotid stenosis under modern intensive medical therapy.
CREST-2 consists of two parallel, observer-blinded randomized controlled trials conducted across 155 centers in five countries.
Trial 1 compared intensive medical management (IMM) alone with carotid-artery stenting (CAS) plus IMM.
Trial 2 compared IMM alone with carotid endarterectomy (CEA) plus IMM.
The primary endpoint was any stroke or death within 44 days after randomization or ipsilateral ischemic stroke up to four years.
Key 4-year results:
Stenting Trial: IMM 6.0% vs. CAS + IMM 2.8% (P = 0.02)
Endarterectomy Trial: IMM 5.3% vs. CEA + IMM 3.7% (P = 0.24)
Periprocedural (Day 0–44):
Stenting trial: 0 strokes/deaths with IMM vs. 7 strokes + 1 death with stenting
CEA trial: 3 strokes with IMM vs. 9 with CEA
Interpretation:
Stenting plus intensive medical therapy provides a significant long-term reduction in ipsilateral stroke risk compared with medical therapy alone. Endarterectomy does not show a statistically significant benefit under contemporary conditions.
These results will be discussed in detail at our ICCA 2026 conference in Frankfurt.
Conference website: https://iccaonline.org