{"doi":"10.3389/fstro.2026.1849877","title":"Treatment of carotid stenosis: an updated review","abstract":"<jats:sec>\n                    <jats:title>Introduction</jats:title>\n                    <jats:p>Atherosclerotic carotid stenosis represents one of the main treatable causes of ischemic stroke, accounting for approximately 10%−15% of all cerebrovascular events. Treatment of this condition has evolved significantly over the past decades, shifting from exclusively surgical approaches to a paradigm that includes optimized medical treatment, carotid endarterectomy, and stenting. Recent 2025 publications, including CREST-2 and ECST-2, have brought paradigm-shifting data that challenge previously established concepts.</jats:p>\n                  </jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective</jats:title>\n                    <jats:p>To provide an extensive and rigorous narrative review on the treatment of carotid stenosis, including common and internal carotid arteries.</jats:p>\n                  </jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods</jats:title>\n                    <jats:p>This narrative review was carried out using the PubMed/MEDLINE, LILACS-VHL, Google Scholar, and SciELO databases. DeCS and MeSH descriptors were employed to identify articles published from 2020 to 2025, without restrictions regarding language or geography.</jats:p>\n                  </jats:sec>\n                  <jats:sec>\n                    <jats:title>Results</jats:title>\n                    <jats:p>\n                      In the CREST-2 stenting trial, adding carotid stenting to optimal medical therapy (OMT) was superior to OMT alone for the 4-year composite primary endpoint (any periprocedural stroke or death, or subsequent ipsilateral ischemic stroke): 2.8% vs. 6.0% (\n                      <jats:italic>p</jats:italic>\n                      = 0.02; number needed to treat = 31). This net benefit was driven by a lower rate of ipsilateral stroke beyond the periprocedural window and was obtained despite a higher upfront periprocedural risk in the stenting arm. In the parallel endarterectomy trial, adding endarterectomy to OMT did not reach statistical significance (3.7% vs. 5.3%; p = 0.24). ECST-2, in its 2-year interim analysis of asymptomatic or low-to-intermediate-risk symptomatic patients, showed no benefit of revascularization added to OMT.\n                    </jats:p>\n                  </jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion</jats:title>\n                    <jats:p>Contemporary data indicate a paradigm shift in the management of carotid stenosis. Optimal medical therapy (OMT), intensified by increasingly stringent LDL-c and blood-pressure targets, is the cornerstone of management for all patients and the principal driver of the marked decline in stroke risk observed over the past two decades. Against this strengthened medical background, the role of revascularization has become more selective: in high-grade asymptomatic stenosis, adding carotid stenting to OMT conferred a modest absolute benefit over OMT alone, whereas carotid endarterectomy (the long-standing gold standard) did not show a statistically significant benefit. These findings support an individualized, plaque- and risk-based strategy in which OMT is universal and revascularization (preferentially by stenting when an intervention is chosen) is reserved for selected patients, with timing and modality guided by stenosis severity, plaque vulnerability, life expectancy, and patient preference.</jats:p>\n                  </jats:sec>","journal":"Frontiers in Stroke","year":2026,"id":617282,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":0,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":null,"is_data_producer":false,"deposit_databanks":null,"is_oa":false,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":null,"fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1591811,"name":"Maria Victória Pimentel Lima","orcid":null,"position":1,"is_corresponding":false},{"id":1591813,"name":"Marina Trombin Marques","orcid":null,"position":2,"is_corresponding":false},{"id":1591814,"name":"Vivian Dias Batista Gagliardi","orcid":null,"position":3,"is_corresponding":false},{"id":1591815,"name":"Rubens Jose Gagliardi","orcid":null,"position":4,"is_corresponding":false},{"id":1591809,"name":"Antônio Vinícius Pimentel Lima","orcid":null,"position":0,"is_corresponding":false}],"reference_count":0,"raw_metadata":{"has_enrichment":true,"resolved":true,"title":"Treatment of carotid stenosis: an updated review","abstract":"<jats:sec>\n                    <jats:title>Introduction</jats:title>\n                    <jats:p>Atherosclerotic carotid stenosis represents one of the main treatable causes of ischemic stroke, accounting for approximately 10%−15% of all cerebrovascular events. Treatment of this condition has evolved significantly over the past decades, shifting from exclusively surgical approaches to a paradigm that includes optimized medical treatment, carotid endarterectomy, and stenting. Recent 2025 publications, including CREST-2 and ECST-2, have brought paradigm-shifting data that challenge previously established concepts.</jats:p>\n                  </jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective</jats:title>\n                    <jats:p>To provide an extensive and rigorous narrative review on the treatment of carotid stenosis, including common and internal carotid arteries.</jats:p>\n                  </jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods</jats:title>\n                    <jats:p>This narrative review was carried out using the PubMed/MEDLINE, LILACS-VHL, Google Scholar, and SciELO databases. DeCS and MeSH descriptors were employed to identify articles published from 2020 to 2025, without restrictions regarding language or geography.</jats:p>\n                  </jats:sec>\n                  <jats:sec>\n                    <jats:title>Results</jats:title>\n                    <jats:p>\n                      In the CREST-2 stenting trial, adding carotid stenting to optimal medical therapy (OMT) was superior to OMT alone for the 4-year composite primary endpoint (any periprocedural stroke or death, or subsequent ipsilateral ischemic stroke): 2.8% vs. 6.0% (\n                      <jats:italic>p</jats:italic>\n                      = 0.02; number needed to treat = 31). This net benefit was driven by a lower rate of ipsilateral stroke beyond the periprocedural window and was obtained despite a higher upfront periprocedural risk in the stenting arm. In the parallel endarterectomy trial, adding endarterectomy to OMT did not reach statistical significance (3.7% vs. 5.3%; p = 0.24). ECST-2, in its 2-year interim analysis of asymptomatic or low-to-intermediate-risk symptomatic patients, showed no benefit of revascularization added to OMT.\n                    </jats:p>\n                  </jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion</jats:title>\n                    <jats:p>Contemporary data indicate a paradigm shift in the management of carotid stenosis. Optimal medical therapy (OMT), intensified by increasingly stringent LDL-c and blood-pressure targets, is the cornerstone of management for all patients and the principal driver of the marked decline in stroke risk observed over the past two decades. Against this strengthened medical background, the role of revascularization has become more selective: in high-grade asymptomatic stenosis, adding carotid stenting to OMT conferred a modest absolute benefit over OMT alone, whereas carotid endarterectomy (the long-standing gold standard) did not show a statistically significant benefit. These findings support an individualized, plaque- and risk-based strategy in which OMT is universal and revascularization (preferentially by stenting when an intervention is chosen) is reserved for selected patients, with timing and modality guided by stenosis severity, plaque vulnerability, life expectancy, and patient preference.</jats:p>\n                  </jats:sec>","is_dataset_classified":null,"base_score":0.0,"endowment":0.0,"datacite_reuse_total":0,"file_count":0,"downloads":0,"views":0,"has_version_chain":false,"is_dataset":false,"is_oa":false,"pmid":"42422475","pmcid":null,"openalex_id":"https://openalex.org/W7165794232","authors":[],"funders":[],"total_grants":0,"fwci":0.0,"citation_percentile":0.78189007,"influential_citations":0,"citation_trend":[],"oa_status":"gold","license":"cc-by","oa_locations":[{"url":"https://www.frontiersin.org/journals/stroke/articles/10.3389/fstro.2026.1849877/pdf","host_type":"journal"},{"url":"https://www.frontiersin.org/journals/stroke/articles/10.3389/fstro.2026.1849877/pdf","host_type":"publisher"},{"url":"https://www.frontiersin.org/articles/10.3389/fstro.2026.1849877/full","host_type":"publisher"},{"url":"https://doi.org/10.3389/fstro.2026.1849877","host_type":"journal"},{"url":"https://pubmed.ncbi.nlm.nih.gov/42422475","host_type":"repository"},{"url":"https://doaj.org/article/5b6aa83d7a2c4a249085be141eeb3490","host_type":"repository"},{"url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC13343524/","host_type":"repository"}],"fields_of_study":["Cerebrovascular and Carotid Artery Diseases","Oropharyngeal Anatomy and Pathologies","Intracranial Aneurysms: Treatment and Complications"],"mesh_terms":[],"keywords":["Carotid endarterectomy","Asymptomatic","Carotid stenting","Stroke (engine)","Stenosis","Endarterectomy","Revascularization","Stent","Atherosclerosis","Angioplasty","Stroke","Carotid stenosis"],"sdg_mappings":[{"sdg_number":0,"sdg_label":"Quality Education"}],"linked_datasets":[],"clinical_trials":[],"software_tools":[],"database_accessions":[],"source":"live","citation_network_status":"fetched"},"created_at":"2026-08-03T01:19:18.381650Z","pmid":null,"pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}