The CREST-2 trial
CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis) was a pair of parallel randomised, observer-blinded trials conducted across 155 centres in five countries, enrolling patients with high-grade (≥70%) asymptomatic carotid stenosis. One trial compared carotid artery stenting (CAS) plus intensive medical management against intensive medical management alone; the other made the same comparison for carotid endarterectomy (CEA). Medical management was genuinely intensive: protocol-driven blood pressure and LDL targets, provided medications, compliance monitoring and lifestyle coaching.
The primary results were published in the New England Journal of Medicine in November 2025 (Brott et al.).
What it found
- Stenting reduced stroke. The primary outcome (any stroke or death within 44 days, or ipsilateral ischaemic stroke to 4 years) occurred in 2.8% of patients treated with stenting plus intensive medical therapy versus 6.0% with medical therapy alone (p = 0.02), a number needed to treat of approximately 31 at four years.
- Endarterectomy did not show a significant benefit over intensive medical therapy alone in the parallel trial (3.7% vs 5.3%, p = 0.24).
- Annual post-procedural ipsilateral stroke risk was 0.4% in the stenting group, against a background of well-delivered medical therapy in which the majority of patients reached risk-factor targets.
The trials address a long-standing question: whether revascularisation adds benefit now that medical therapy has improved substantially since the original carotid trials. In the stenting comparison, in credentialed centres and selected patients, a benefit was demonstrated. Interpretation of the trials, including the endarterectomy comparison, remains the subject of discussion in the surgical and neurological literature, and the findings inform rather than replace individualised judgement.
Am I (or is my patient) in the CREST-2 population?
The trial's benefit applies to patients who resemble its participants. The key inclusion criteria were:
- Age 35 years or older
- Severe carotid stenosis (≥70%) confirmed on imaging (catheter angiography, or ultrasound/CTA/MRA meeting defined criteria)
- Asymptomatic: no stroke or transient ischaemic attack attributable to that artery within the previous 180 days
- Anatomy suitable for revascularisation, and fitness for the procedure
- No prior revascularisation of the same artery, and no other condition (such as atrial fibrillation requiring anticoagulation with high embolic risk, severe comorbidity limiting life expectancy) that would confound treatment
A patient with asymptomatic carotid stenosis of 70% or greater who is medically stable and has a reasonable life expectancy may be considered for carotid stenting in addition to intensive medical therapy. Patients with recent symptoms fall outside CREST-2 and are managed on the established symptomatic-disease pathway.
How assessment works
Assessment involves review of the imaging (with dedicated CT or catheter angiography where needed to confirm the degree of stenosis and plaque anatomy), review of vascular risk factors and medications, and discussion of the options with the patient and the referring team: intensive medical therapy, stenting or surgery. Trial results describe populations; anatomy, age, comorbidity and patient preference all bear on the decision for an individual.
Referring clinicians are welcome to send imaging with the referral; patients being assessed should bring any scans and a current medication list.
Key references
Brott TG, et al. Medical Management and Revascularization for Asymptomatic Carotid Stenosis. N Engl J Med. 2026;394(3):219–231.
Meschia JF, Lal B, Brott T. CREST-2: Early reflections on the primary results. Semin Vasc Surg. 2026;39(1):52–57.