Intensive medical management, revascularization and algorithms
New research and strategies point the way to the future of carotid artery disease treatment.
Medical science’s understanding of carotid artery disease is changing fast — thanks to studies that spotlight treatments and methods to streamline decision-making for both asymptomatic and symptomatic patients.
In the Thursday session, “Carotid Artery Disease in 2026 as Informed by Randomized Trials and Other Studies,” experts will discuss some of the latest research into carotid artery disease and describe how that research can translate into practice.
Asymptomatic versus symptomatic patients are very different populations, said James Meschia, MD, FAHA, neurology researcher and professor of neurology at the Mayo Clinic in Jacksonville, Florida, and a presenter at the session Thursday.
“There is an urgency to treating symptomatic patients that does not exist with asymptomatic patients. Early treatment is considered more effective at preventing stroke after a patient has experienced a transient ischemic attack or minor stroke.”
One of the key studies that will be highlighted during the session is “Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Study” (CREST-2), which began enrolling participants in 2024 and whose results were recently published in the New England Journal of Medicine. The study compared intensive medical management (IMM) alone to IMM combined with revascularization in asymptomatic patients with carotid artery narrowing.
The trial focused on two revascularization procedures: carotid endarterectomy and carotid stenting. All participants received IMM to help control stroke risk factors. Half the patients were randomly assigned to IMM alone or IMM plus endarterectomy. The other half of the patients were randomly assigned to IMM alone or IMM plus stenting.
The addition of stenting led to a lower risk than IMM alone for the composite endpoint of perioperative stroke or death, or stroke on the same side of the body within four years, the researchers found. Carotid endarterectomy did not result in significant benefit to the patient.
Although the study did not find benefits of revascularization across the board, Meschia said that it did demonstrate a reduction in risk of future stroke among certain patients, and that revascularization should play a key role in modern stroke prevention.
Meschia noted that CREST-2 was much larger than prior recent trials. A key point, he said, is that the trial did not pit one treatment against another. Rather, it showed that all the treatments involved are viable options.
“This was not a medicine versus revascularization trial, but a medicine and revascularization trial,” he said. “The medical care of patients in the trial, while intensive, is achievable in real-world clinical practice.”
Although CREST-2 trial focused only on two types of revascularization, Meschia said it’s important to be aware of other types of revascularization, such as transcarotid artery revascularization (TCAR). But he cautioned that TCAR’s full implications have not yet been clarified.
“(TCAR) appears to have relatively lower procedural risk of stroke than transfemoral stenting,” he said. “But there is no reliable evidence that, post-procedurally, TCAR is superior to transfemoral stenting.”
Revascularization or IMM is just one piece of the picture. Carotid plaque imaging plays a critical role in determining how high of a risk a patient is at for a stroke and what preventive steps can be taken.
John Huston, MD, professor of radiology at the Mayo Clinic in Rochester, Minnesota, will discuss an algorithm that could aid in determining that risk in his presentation, “Carotid Plaque Imaging: Can There Be a Widely Acceptable Algorithm Integrating Plaque Characteristics With Stenosis That Can Guide Everyday Decision Making?”
Huston, who is also associate chair of research in radiology at the Mayo Clinic, said the use of such an algorithm would be important to the overall treatment of carotid artery disease because it would align imaging, risk stratification and management decisions with the true mechanisms of stroke.
The most common initial screening methods for carotid artery disease are ultrasound and CT scans. Huston said each of these has its advantages and drawbacks.
“Ultrasound does not directly measure luminal narrowing; rather it is inferred from flow velocities. It is also operator-dependent and cannot reliably characterize plaque surface or composition,” he said. “CT better identifies the risk factor of ulceration and some plaque features, compared with ultrasound; however, calcified plaques can result in overestimation of stenosis CT. Magnetic resonance imaging (MRI) remains the gold standard for this kind of plaque characterization, particularly for detecting intraplaque hemorrhage.”
With all these choices, Huston said adding an algorithm to the decision-making process could help better manage what methods are used and how, and ultimately provide better results.
“The algorithm would provide a step-by-step process to confidently determine both the degree of stenosis and plaque features such as intraplaque hemorrhage — the strongest risk factor for stroke,” he said.
An algorithm integrating stenosis and plaque vulnerability is essential, he said, because it identifies high-risk carotid disease that stenosis alone cannot.
“It enables earlier and more effective stroke prevention,” Huston said. “This aligns with modern stroke prevention goals which emphasize personalized medicine to prevent first and recurrent ischemic events.”
