This Neurology commentary reads CREST-2 as settling a long argument: in high-grade asymptomatic carotid stenosis, stenting combined with intensive medical management reduced stroke risk compared with intensive medical management alone. The framing matters - stenting is positioned as an adjunct to optimal medical therapy, not as a competitor to it.
Two conditions run through the piece. The first is patient selection, and the second is operator skill: a procedural complication rate achievable in a trial is not automatically achievable in every centre, and the benefit disappears quickly if it is not. This is the part that does not transfer by publication.
Medical management has also improved substantially since the older trials, which is why the comparison had to be redone at all, and it will keep improving. That argues for revisiting the balance periodically rather than treating a single result as permanent.
The practical instruction is shared decision-making, with real numbers attached to the centre doing the procedure rather than to the trial. In Indian practice, where high-volume and low-volume carotid centres sit side by side, that local complication rate is the number that decides whether this evidence applies to the patient in front of you.
- Optimise medical therapy first and completely - stenting was tested as an addition to it, not instead of it
- Ask for the operating centre's own complication rate before quoting the trial's
- Reserve the discussion for high-grade asymptomatic stenosis, which is the population studied
- Document the shared decision, including what the patient was told about periprocedural stroke risk
- Reassess the balance as medical therapy improves rather than treating this as a fixed answer
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