German registry shows sharp rise in carotid artery stenting as CREST-2 reshapes prevention

Carotid artery stenting (CAS) procedures increased by almost 30% in Germany in 2025 while maintaining a technical success rate of 93%, according to new data from the joint quality assurance registry of the German Society of Interventional Radiology and Minimally Invasive Therapy (DeGIR) and the German Society of Neuroradiology (DGNR).

The nationwide registry documented 5,623 CAS procedures in 2025, up from 4,357 in 2024. At the same time, procedural success remained consistently high, with 5,219 of the treated carotid stenoses (93%) successfully reopened, compared with 92% the previous year.

Carotid artery stenosis, a narrowing of the carotid arteries caused by atherosclerotic plaque, is a major cause of ischemic stroke, responsible for an estimated 10% to 20% of cases. While many patients remain asymptomatic, severe stenosis substantially increases the risk of future stroke. 

However, advances in intensive medical therapy, including statins, antiplatelet agents, and blood pressure control, have significantly lowered stroke risk over the past two decades, fueling debate over which patients still benefit from carotid revascularization.

CREST-2 adds new randomized evidence

The German registry update comes as the recently published CREST-2 program adds new randomized evidence to that debate. Published in the New England Journal of Medicine, the multicenter study comprised two parallel randomized trials involving more than 2,400 patients with high-grade asymptomatic carotid stenosis. 

One trial compared carotid artery stenting plus intensive medical therapy with intensive medical therapy alone, while the second evaluated carotid endarterectomy plus intensive medical therapy against intensive medical therapy alone.

In the carotid artery stenting trial, the four-year incidence of stroke or death was 2.8% among patients treated with stenting plus intensive medical therapy, compared with 6.0% among patients receiving medical therapy alone, representing a statistically significant reduction in risk. 

After the peri-procedural period, annual ipsilateral stroke rates also remained lower in the stenting group. By contrast, the parallel trial evaluating carotid endarterectomy did not demonstrate a statistically significant benefit over intensive medical therapy alone for its primary endpoint.

"The CREST-2 data show that carotid artery stenting prevents strokes in patients with asymptomatic carotid stenosis compared with medical therapy alone," said Dr. Wiebke Kurre, chief of radiology and neuroradiology at Klinikum Passau in Germany. 

"The findings demonstrate that minimally invasive neurointerventional procedures play an important role in modern stroke prevention when patient selection is appropriate, treatment pathways are standardized, and interventions are performed with high quality", she added.

Registry highlights growing role of minimally invasive treatment

According to DeGIR and DGNR, the increasing number of carotid artery stenting procedures reflects the growing role of catheter-based therapies in stroke prevention, particularly as Europe's population continues to age and the burden of atherosclerotic vascular disease increases. 

Unlike carotid endarterectomy, carotid artery stenting restores blood flow through a catheter-based approach without open neck surgery and may offer faster recovery in appropriately selected patients.

The societies also emphasized the importance of quality assurance in achieving favorable outcomes. More than 300 hospitals contribute standardized procedural data to the nationwide DeGIR-DGNR registry, which documented more than 230,000 image-guided interventions in 2025, including nearly 40,000 neurovascular procedures. 

Together with the organizations' physician certification program, the registry provides real-world evidence that complements randomized clinical trials while helping to maintain consistently high standards of care across Germany.