In the first instalment of a two-part roundtable discussion on the fallout from CREST-2, William Gray (Main Line Health, Philadelphia, USA) is joined in the CX Studio by Sonya Noor (Buffalo Endovascular and Vascular Surgical Associates, Buffalo, USA) and Richard Bulbulia (University of Oxford, Oxford, UK) to talk through the implications for medical therapy, carotid stenting and endarterectomy in the context of asymptomatic carotid artery stenosis.
Watch the second instalment—Unpacking CREST-2, part two: “It’s a public health benefit to revascularize patients based on CREST-2”—here.
Dear Editor, We read with great interest the article “Medical management and Revascularization for Asymptomatic Carotid Stenosis” by Brott TG et al.1The Investigators of the CREST-2 trial concluded that, in asymptomatic high-grade carotid stenosis, the addition of stenting (CAS) to medical management alone led to a lower risk of severe complication within 4 years, while endarterectomy (CEA) did not. The zealots of CAS welcomed these results with celebrations. Nevertheless, the study, albeit of broad scope, presents some weak points, or at least aspects that still need to stand the test of time. First, the medical-therapy group of the CEA trial had three strokes, while in the same group of the CAS trial no strokes happened: considering that the two medical-therapy group had to be identical to give reliable results, especially when involved small numbers, this constitutes, in our opinion, a bias. Furthermore, a stroke rate of 1.5% in the CEA trial is nowadays unacceptable in high-volume centres: in our centre, we manage around 150 CEA per year with a medium annual stroke rate of 0.6%.