Adding carotid-artery stenting—but not carotid endarterectomy—to intensive medical management reduced the risk of stroke or death in patients with high-grade asymptomatic carotid stenosis. In two parallel, observer-blinded trials including more than 2,400 participants with ≥70% stenosis, the 4-year incidence of the primary composite outcome (any stroke or death from randomization to 44 days, or ipsilateral ischemic stroke during the remaining follow-up period up to 4 years) was significantly lower with stenting than with medical therapy alone (2.8% vs. 6.0%), whereas endarterectomy showed no significant advantage over medical therapy (3.7% vs. 5.3%). Early perioperative risks differed across interventions: in the stenting trial, eight events (seven strokes, one death) occurred during the first 44 days in the stenting group versus none in the medical-therapy group, and in the endarterectomy trial, nine strokes occurred in the endarterectomy group versus three with medical therapy. Overall, these results suggest that in asymptomatic high-grade carotid stenosis, stenting can offer added protection against future ipsilateral stroke, whereas endarterectomy does not provide a clear incremental benefit over intensive medical therapy alone. The benefit from revascularization of asymptomatic carotid stenosis for stroke prevention has become small with improved medical therapy. Source: https://www.nejm.org/
