# Reconsidering Carotid Artery Stenting for Asymptomatic Carotid Stenosis in the Era of Endovascular Evolution

## TL;DR

This paper discusses the potential for carotid artery stenting to be reconsidered for treating severe asymptomatic carotid stenosis based on new trial evidence.

## Contribution

The paper highlights new evidence from the CREST-2 trial suggesting carotid artery stenting may reduce stroke risk compared to medical therapy alone.

## Key findings

- Carotid artery stenting showed a significant long-term reduction in ipsilateral ischemic stroke compared to medical therapy alone.
- Current guidelines may need reevaluation based on recent findings from the CREST-2 trial.

## Abstract

Management strategies in asymptomatic carotid artery stenosis are largely centered on intensive medical management, with carotid revascularization via endarterectomy or carotid artery stenting being reserved for select patients. This decision may be based on stenosis severity, perioperative risk, and patient preference. Current guidelines emphasize shared decision-making for patients with severe (>70%) stenosis, informed by prior trial data that does not demonstrate superiority of revascularization over independent medical therapy. Other studies more specifically recommend carotid endarterectomy over carotid artery stenting for asymptomatic patients with >60% stenosis. However, these studies are limited by poor statistical power. Recent findings in the CREST-2 trial have challenged this discussion of medical management as an independent primary course of action. The carotid artery stenting arm demonstrated significant long-term reduction in ipsilateral ischemic stroke compared to medical therapy alone. In this perspective, we argue that this new evidence supports a renewed role for carotid artery stenting in carefully selected patients with severe asymptomatic carotid artery stenting.