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Efficacy of carotid artery stenting in patients with symptomatic low-grade carotid artery stenosis. OBJECTIVE: Over the past decade, medical therapy has been the gold standard for patients with symptomatic low-grade cervical carotid artery stenosis. Recent advances in imaging techniques for diagnosing unstable plaques have led to evolving and innovative endovascular treatments. The aim of this study was to investigate the efficacy of carotid artery stenting (CAS) and examine differences in outcomes between medical therapy alone versus with CAS. METHODS: Consecutive patients with ischemic stroke due to low-grade carotid artery stenosis (< 50% per North American Symptomatic Carotid Endarterectomy Trial criteria) treated from April 2017 to January 2024 at a single center were analyzed in this retrospective study. Patients received either medical therapy alone or medical therapy followed by CAS. The majority of CAS procedures (98%) were performed with closed-cell stents using the flow-reversal method. Patient medical records were reviewed and plaque features were assessed using multiple imaging modalities. Factors associated with recurrence of ischemic stroke after each treatment were also evaluated. Multivariable Cox regression and Kaplan-Meier analyses were performed to assess differences between treatment groups. RESULTS: Eighty-four patients (70 male, median age 77 years) were included in this analysis; 44 received medical therapy alone and 40 underwent CAS following medical therapy. In the medical therapy alone group, 27 patients (61%, 26%/patient-year) had new lesions on diffusion-weighted imaging, including 20 (45%, 21%/patient-year) with recurrent symptomatic stroke at the midterm follow-up (median 23 months, IQR 7.9-51 months). Factors associated with recurrence after medical therapy alone included dyslipidemia (HR 5.1) and intraplaque hemorrhage (HR 5.5). In the CAS group, 1 patient (2.5%, 0.8%/patient-year) had a stroke due to an in-stent plaque 4 years after CAS. Kaplan-Meier analysis of recurrent stroke showed a significantly lower rate in the CAS group compared with the medical therapy alone group (p < 0.001). CONCLUSIONS: CAS has potential as a safe and valid treatment option for symptomatic low-grade carotid artery stenosis. The treatment strategy should be carefully considered in patients with dyslipidemia and unstable plaques with a high T1PMR on MRI.