Yu Gaoa b c, Lijun Wangb c, Hongjian Zhangc d, Xiaoxi Zhangb c, Yongxin Zhangb c, Chuanchuan Wangb c, Hongjian Shenb c, Pengfei Xingb c, Zifu Lib c, Yongwei Zhangb c, Jens Fiehler
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Background: Historical trials (ACAS/ACST) supported revascularization for asymptomatic carotid stenosis, but contemporary medical management with statins, antithrombotics, and blood pressure control may reduce stroke risk. This meta-analysis compares medical management versus revascularization (carotid endarterectomy [CEA] or stenting [CAS]) in current practice. Methods: We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to "Asymptomatic Carotid Stenosis", "Medical Management" and "Revascularization" until December 5, 2025. The primary outcome was a composite of any stroke (ischemic or hemorrhagic) or death, assessed from randomization to the peri-procedural period, or ipsilateral ischemic stroke, assessed during the remaining follow-up. This study was registered in PROSPERO, CRD420251247217. Results: Three RCTs (SPACE-2, ECST-2, CREST-2; 3,426 patients) were included. For the primary outcome, no significant difference existed between revascularization (CEA/CAS) and medical management: 4.76% (88/1,847) vs. 6.40% (101/1,579); RR 0.91 (95% CI 0.47-1.74, P = 0.77) though heterogeneity was high (I 2 = 74%). All-cause mortality also did not differ: 7.7% vs. 9.50%; RR 0.83 (95% CI 0.67-1.04, P = 0.77). Subgroup analysis showed no benefit for CEA (RR 0.73, 95% CI 0.45-1.19) or CAS (RR 0.72, 95% CI 0.23-2.27) over medical management alone. Conclusion: The present meta-analysis demonstrates that, among patients with asymptomatic carotid stenosis, the risk of stroke and mortality with contemporary medical management is comparable to that with revascularization (CEA or CAS). These findings validate current guideline recommendations, which emphasize stringent patient selection and prioritize the optimization of medical therapy prior to any revascularization procedure.
