For years, the management of patients with asymptomatic carotid stenosis has been a major clinical dilemma, leaving open questions about whether, when and how to intervene. The international CREST-2 study, recently published in the New England Journal of Medicine, now provides clear answers based on solid scientific evidence.
With more than 2,400 patients enrolled between 2014 and 2025 in referral centers, CREST-2 is the largest study ever conducted on this condition. Results show that in patients with significant stenosis, carotid stenting combined with intensive medical therapy significantly reduces the four-year risk of stroke compared with drug therapy alone, from 6.0% to 2.8%. The stenting procedure is confirmed to be minimally invasive, safe, and effective, especially when performed in high-volume, highly experienced centers, highlighting how team organization and care setting are crucial to clinical outcomes.
The study also stresses the importance of proper patient selection, which cannot be based solely on the degree of stenosis, but must include assessment of the risk profile, life expectancy and expertise of the referral center. In this scenario, realities such as Policlinico Casilino, characterized by a multidisciplinary approach and a high caseload, represent a virtuous model. Early diagnosis, obtainable through a simple Echo-color-Doppler of the epiaortic vessels, remains a fundamental element of the prevention pathway.
While intensive medical therapy remains the mainstay of treatment, CREST-2 demonstrates that in a selected proportion of patients, the addition of stenting enables more effective, informed, and personalized stroke prevention.
