A critical analysis of the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) and the European Carotid Surgery Trial (ECST)-2.

The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) concluded that addition of transfemoral carotid artery stenting to intensive medical therapy (IMT) among patients with high-grade Asymptomatic Carotid Artery Stenosis (AsxCS) led to a significantly lower risk of periprocedural stroke/death or postprocedural ipsilateral stroke within 4 years as compared with IMT alone. In contrast, addition of carotid endarterectomy (CEA) did not lead to statistically significant benefit. The current article critically reviews the results of CREST-2 and shows that with a longer follow-up, CEA + IMT may show a significant benefit compared with IMT alone (similarly with carotid artery stenting + IMT). Secondly, it provides the rationale showing why IMT alone may not provide adequate stroke prevention for patients with severe (70% to 99%) AsxCS. Thirdly, it compares CREST-2 with another recent randomized controlled trial comparing CEA + optimized medical treatment vs optimized medical treatment alone for patients with AsxCS and low-to-intermediate risk symptomatic carotid stenosis, the European Carotid Surgery Trial-2. Furthermore, it discusses the flaws and limitations in European Carotid Surgery Trial-2. Finally, it provides the rationale to refute the often-quoted argument that the vast majority of AsxCS patients are offered an unnecessary intervention. There is now Level I Evidence suggesting that a carotid intervention + IMT may be superior to IMT alone for the management of AsxCS patients.