ISC 2026 | Projected long-term benefit of carotid revascularization in asymptomatic carotid stenosis: CREST-2

Actually, it’s the CREST-2 trials. There are two of them. And both of them are asking a similar question, which is, does revascularization lower stroke and death risk? One of them is randomizing people to carotid endarterectomy plus best medical management versus medical management alone. And the other is carotid stenting plus best medical management versus medical management alone. So it’s actually two trials. The patients were followed for up to four years with the primary outcome being how big of a difference in the stroke risk is there at the four-year point. As I’ve said, the outcome was the risk at four years. But of course, you don’t get a revascularization of your carotid artery with the idea that you’ll only benefit for four years and then the benefit stops. And so what I’ll be speaking on is, is there any evidence of a change in the magnitude of the treatment effect over that four-year period? And it proved there were not. And then with that, you can say, well, what happens if we continue at this rate, say, out to 10 years? And if you continue out to 10 years, about one in six patients who are managed medically will have a stroke compared to one in 20 who are managed with revascularization. And so it’s basically talking more about the projected long-term benefit for carotid stenting and endarterectomy. Fortunately, there were remarkably few events, stroke events, in these trials. So there weren’t but around 45 stroke events in each one of the two trials. And so finding that group of patients that really benefits more is more than challenging because there aren’t many people having events. They’re being managed so well that relatively few people are having events. We would speculate that people with a tighter stenosis, higher peak systolic velocity flow might benefit more, but that work is underway. Well, what we showed was pretty definitively that revascularization, the addition of revascularization with stenting, really reduces stroke risk. It cuts it by about half over a four-year period. And again, if you extend it out further, the benefit becomes, we presume, bigger with longer time. That’s a prediction. Predictions are risky, but perhaps it’s even larger if we go out further. We did not show a benefit for an endarterectomy. That doesn’t mean it wasn’t working. That just means we failed to reach the magic 0.05 level for significance. The benefit for an endarterectomy was actually fairly similar to stenting, but was not statistically significant. I would say that if it were me or my wife had a high-grade stenosis, I think what these data suggest is that you can really reduce your risk by having your artery revascularized, certainly by stenting and perhaps by endarterectomy.

This transcript is AI-generated. While we strive for accuracy, please verify this copy with the video.