Long-Term Study Finds Equal Effectiveness of Surgery and Stenting in Preventing Stroke from Carotid Artery Disease

Recent long-term findings from the largest randomized trial comparing carotid artery surgery and stenting show that both procedures offer similar protection against stroke in patients with carotid artery disease. The trial, known as ACST-2, involved 3,624 participants across 33 countries who had been diagnosed with asymptomatic carotid stenosis, meaning they had a narrowing of the carotid arteries without experiencing a stroke. Participants were randomly assigned to undergo either carotid endarterectomy (CEA), a surgical removal of plaque, or carotid artery stenting (CAS), a less invasive procedure involving balloon angioplasty followed by stent placement to keep the artery open. The participants were followed for a median of over eight years, with some observed for nearly two decades. Key results demonstrated that both treatments had comparable rates of preventing the first stroke, with approximately 113 strokes in the CAS group versus 112 in the CEA group. When excluding strokes caused by factors other than carotid artery disease, the numbers remained similar. The study also found that strokes occurring on the same side as the treated artery (ipsilateral strokes) were significantly fewer in both groups, confirming the protective effect of both procedures. Notably, over 99% of arteries remained open after one month, and only 4% of participants in each group required additional procedures long-term. The 30-day risk of death or disabling stroke was about 1% for both procedures. Experts involved in the study, including Professor Alison Halliday and Professor Richard Bulbulia from Oxford Population Health, emphasized that these results provide confidence for physicians to choose the most suitable procedure based on individual patient circumstances. While CAS is generally less invasive and may be preferred for high-risk patients, it carries a slightly higher risk of stroke shortly after the procedure. Nevertheless, the long-term outcomes are encouraging, showing both options are highly safe and effective in preventing strokes caused by carotid artery disease. The findings, presented at the European Society of Cardiology Congress 2025, reinforce that with appropriate patient selection, both surgical and stenting procedures can be reliably used to reduce stroke risk.