Carotid Stenting in Carotid Stenosis Management—A Gamechanger After CREST-2?

The recently published CREST-2 trial [1] represents a potentially pivotal moment in the management of asymptomatic extracranial carotid artery stenosis.The accompanying NEJM editorial by Brown and Bonati [2] appropriately highlights the effectiveness of optimized medical therapy.However, a focused interpretation from the perspective of neuroradiology and neurointervention is essential and leads to a partially different conclusion.Rather than suggesting that asymptomatic stenoses should be managed conservatively in general, the results indicate that intervention-particularly carotid artery stenting (CAS)-should be applied when treatment is necessary, and under optimal conditions, can be considered a leading option.CREST-2 compared interventional therapy (either CAS or carotid endarterectomy [CEA] combined with medical treatment) versus medical therapy alone.While the conservative arm reported low event rates, the intervention arms also demonstrated very low periprocedural complication rates-significantly lower than in earlier generations of trials.This finding becomes especially relevant when contextualized with data from , where CAS showed near equivalence to CEA in asymptomatic patients.Looking retrospectively at landmark studies in symptomatic stenosis such as SPACE-1, CREST [4], EVA-3S [5] and ICSS [6], a clear trend becomes evident: Over the last decade, CAS outcomes have significantly improved.