An audience poll asking, ‘What do we believe: ECST-2 or CREST- 2?’ following a debate at the 2026 Charing Cross (CX) Symposium (21–23 April, London, UK) revealed a closer-than-expected result, with attendees voting 60-40 in favour of the latter. Subsequent discussion highlighted the pressing need for a cost-effectiveness analysis.
While ECST-2 supports treating patients with asymptomatic and low- or intermediate-risk symptomatic carotid stenosis with optimal medical therapy alone, CREST-2 concluded that intensive medical therapy (IMT) plus revascularisation with stenting is superior to IMT alone and IMT plus revascularisation with surgery is non-inferior to IMT alone.
“I would suggest to you that we are completely biased, and we need to think about patient preference,” said Alun Davies (Imperial College London, London, UK) in the concluding remarks of his argument for ECST-2. He concluded that it is “probably inappropriate to offer carotid revascularisation to any patient and they should all probably be treated with best medical therapy, other than one or two exceptions”.
William Gray (Main Line Health, Wynnewood, USA), on the other hand, argued that “CREST-2 conclusions are the only believable ones”. ECST-2, he said, was an “ill conceived, poorly conducted, borderline unethical and incomplete trial”, rendering its published conclusions moot.
Richard Bulbulia (University of Oxford, Oxford, UK) then took stock of the debate from the auditorium floor, echoing CREST-2’s win in the audience poll. “The important question these contemporary carotid trials sought to answer was, what is the additional benefit of carotid intervention given 21st century medical therapy? And the answer is clear in CREST-2,” he said.
Bulbulia continued that, considering the field of carotid intervention more widely, “some patients are best treated with medical therapy alone; there’s carotid stenting, there’s carotid surgery, and there’s TCAR [transcarotid artery revascularisation], and really it’s a multidisciplinary team working to decide what’s the best treatment for the right patient.”
Speaking from the panel, Davies then raised the “key question” of cost-effectiveness, which he noted “has not been really addressed properly by either study”. On this note, Bulbulia cautioned against seeing intervention as inherently more costly. “There’s the cost of intervention, but there’s also the cost of strokes that you’re failing to prevent,” he stressed, highlighting the need for a cost-effectiveness analysis of the latest data.
