Carotid Artery Stenting: Evolution, Evidence, and Contemporary Practice in the Era of Intensive Medical Therapy
Abstract
1. Introduction
2. Historical Perspectives
3. Present Day Practice: Medical Optimization and Stenting
4. Discussion
4.1. Limitations
4.2. Future Perspectives
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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| Trial | Year | Population | Comparison | Primary Endpoint | Key Findings | Clinical Impact |
|---|---|---|---|---|---|---|
| NASCET | 1991 | Symptomatic ≥ 70% stenosis | CEA vs. medical therapy | Ipsilateral stroke | CEA significantly reduced stroke risk | Established CEA as gold standard for symptomatic high-grade stenosis |
| ECST | 1998 | Symptomatic carotid stenosis | CEA vs. medical therapy | Stroke/death | Confirmed benefit of CEA in severe stenosis | Reinforced surgical management |
| ACAS | 1995 | Asymptomatic ≥ 60% stenosis | CEA vs. medical therapy | Ipsilateral stroke/death | CEA reduced 5-year stroke risk | Expanded CEA to selected asymptomatic patients |
| ACST | 2004 | Asymptomatic stenosis | CEA vs. medical therapy | Stroke risk reduction | Long-term stroke reduction with CEA | Supported surgical intervention in selected asymptomatic patients |
| SAPPHIRE | 2004 | High surgical-risk patients | CAS vs. CEA | Death/stroke/MI at 30 days + 1 year | CAS is non-inferior to CEA | Led to FDA approval of CAS in high-risk patients |
| SPACE | 2006 | Symptomatic ≥ 70% stenosis | CAS vs. CEA | Stroke/death at 30 days | Failed to prove non-inferiority of CAS | Highlighted need for embolic protection and operator expertise |
| CREST | 2010 | Symptomatic + asymptomatic | CAS vs. CEA | Composite: stroke/MI/death | No significant difference overall; CAS ↑ stroke, CEA ↑ MI | Established CAS as alternative in selected patients |
| CREST-2 | Ongoing/Recent | Asymptomatic ≥ 70% stenosis | CAS + medical vs. medical alone; CEA + medical vs. medical alone | Stroke/death | Intensive medical therapy substantially reduces stroke risk; revascularization still beneficial in selected cases | Refined indications for intervention in asymptomatic disease |
| Treatment Type | Key Components/Description | Representative Trials/Evidence | Clinical Notes/Outcomes |
|---|---|---|---|
| Lifestyle Modification & Risk Factor Management | Diet, physical activity, smoking cessation, alcohol moderation, blood pressure, diabetes, lipid control | Luedemann et al., 2002 [4]; Bhat et al., 2019 [5] | Improves carotid intima-media thickness (CIMT) and reduces early atherosclerosis; often underrepresented in landmark trials |
| Medical Therapy | Antiplatelet therapy, statins, blood pressure control, risk factor optimization | CREST-2 (CAS + medical vs. medical alone; CEA + medical vs. medical alone) | Reduces stroke risk, particularly in asymptomatic patients; foundation of modern management |
| Carotid Endarterectomy (CEA) | Surgical removal of plaque from carotid artery | NASCET 1991; ECST 1998; ACAS 1995; ACST 2004 | Gold standard for symptomatic high-grade stenosis; reduces ipsilateral stroke risk; also beneficial in selected asymptomatic patients |
| Carotid Artery Stenting (CAS) | Percutaneous stent placement with/without embolic protection | SAPPHIRE 2004; SPACE 2006; CREST 2010 | Less invasive alternative to CEA; good long-term outcomes in selected patients; peri-procedural stroke risk must be considered |
| Transcarotid Artery Revascularization (TCAR) | Hybrid approach with direct carotid access and flow reversal | ROADSTER 2015–2019 | Emerging technique for high-risk patients; may reduce embolic complications; evidence still evolving |
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Dixit, S.; Anamika, F.; Multani, A.; Rosenzveig, A.; Kathirvel, B.; Degala, S.; Thalamati, M.; Kirksey, L.; Bajzer, C.; Raskin, D.; et al. Carotid Artery Stenting: Evolution, Evidence, and Contemporary Practice in the Era of Intensive Medical Therapy. Life 2026, 16, 601. https://doi.org/10.3390/life16040601
Dixit S, Anamika F, Multani A, Rosenzveig A, Kathirvel B, Degala S, Thalamati M, Kirksey L, Bajzer C, Raskin D, et al. Carotid Artery Stenting: Evolution, Evidence, and Contemporary Practice in the Era of Intensive Medical Therapy. Life. 2026; 16(4):601. https://doi.org/10.3390/life16040601
Chicago/Turabian StyleDixit, Sakshi, FNU Anamika, Anmol Multani, Akiva Rosenzveig, Bargavi Kathirvel, Suprita Degala, Manvitha Thalamati, Lee Kirksey, Christopher Bajzer, Daniel Raskin, and et al. 2026. "Carotid Artery Stenting: Evolution, Evidence, and Contemporary Practice in the Era of Intensive Medical Therapy" Life 16, no. 4: 601. https://doi.org/10.3390/life16040601
APA StyleDixit, S., Anamika, F., Multani, A., Rosenzveig, A., Kathirvel, B., Degala, S., Thalamati, M., Kirksey, L., Bajzer, C., Raskin, D., & Nanjundappa, A. (2026). Carotid Artery Stenting: Evolution, Evidence, and Contemporary Practice in the Era of Intensive Medical Therapy. Life, 16(4), 601. https://doi.org/10.3390/life16040601

