An editorial published in CVIR Endovascular argues that carotid artery stenting (CAS) should be considered a first-line treatment option for appropriately selected patients with both symptomatic and asymptomatic carotid artery stenosis, contending that recent evidence, led by the CREST-2 trial results, marks a turning point for the procedure.
The article, led by Stefan Müller-Hülsbeck (Malteser Fördeklinikum St Katharina, Flensburg, Germany) and colleagues, examines how evolving evidence and contemporary clinical practice could reshape the role of CAS. The authors argue that the field has moved beyond questions of whether carotid stenting is effective and should instead focus on identifying which patients are most likely to benefit from intervention.
The publication follows the release of results from CREST-2, widely regarded as one of the most anticipated carotid trials in recent years. While debate continues over how the findings should influence practice, Müller-Hülsbeck et al suggest the study has strengthened the case for carotid stenting in carefully selected patients—particularly when performed in experienced centres using state-of-the-art devices.
The authors ask: “Has carotid artery stenting reached prime time?” and their answer is unequivocally “yes”.
The editorial acknowledges that current guideline recommendations remain cautious, particularly in asymptomatic carotid disease. While carotid endarterectomy continues to be regarded as the standard treatment for many patients requiring intervention, the authors argue that the evidence base underpinning CAS has evolved considerably since many of those recommendations were written.
Rather than viewing CREST-2 in isolation, they place it alongside findings from studies including SPACE-2 and ECST-2, as well as contemporary registry data, arguing that together they demonstrate the safety and effectiveness of carotid stenting in appropriately selected patients.
However, not all commentators have interpreted the evidence in the same way, as the authors highlight differing reactions following publication of CREST-2. Some have suggested that the trial reinforces the value of intensive medical therapy, while others have argued that it supports broader use of carotid revascularisation. The Society for Vascular Surgery (SVS), for example, concluded that the study “does not change standards of care”, while continuing to support carotid endarterectomy, transfemoral CAS and transcarotid artery revascularisation (TCAR) in appropriately selected patients. Müller-Hülsbeck and colleagues argue that these differing interpretations reflect a field in transition rather than one in disagreement.
The editorial also places focus on significant changes in carotid stenting practice since the early randomised trials. The authors note that most patients enrolled in CREST-2 were treated with first-generation single-layer carotid stents. Since then, mesh-covered and dual-layer devices have become increasingly available, designed to reduce plaque prolapse and distal embolization by providing improved plaque coverage. Combined with advances in embolic protection systems, imaging, procedural technique and operator experience, they argue these developments have contributed to improved procedural safety. Consequently, the authors suggest that outcomes reported in contemporary practice may underestimate what can now be achieved using current-generation technology.
Müller-Hülsbeck et al emphasise that patient selection remains central to the discussion and advocate for a tailored approach based on plaque characteristics, anatomical suitability, life expectancy and procedural expertise. The authors also reiterate the importance of multidisciplinary decision-making and adherence to established standards of practice.
Looking ahead, Müller-Hülsbeck and colleagues call for future guideline updates to reflect the growing body of evidence supporting CAS. They also acknowledge that while further randomised trials evaluating newer-generation stents would be valuable, such studies may prove difficult to undertake because of cost and logistical challenges.
Concluding their editorial, the authors underscore the “bright future” ahead for stenting and minimally invasive treatment in “experienced hands”. They determine that the combination of contemporary evidence, technological advancements and developing operator expertise will enable carotid stenting to be placed alongside surgery as a routine treatment option for selected patients, rather than as an alternative reserved for highly specific clinical scenarios.
