Purpose Advances in contemporary medical therapy have prompted re-evaluation of the role of carotid revascularisation in asymptomatic carotid stenosis. The CREST-2 trial was designed to determine whether carotid endarterectomy (CEA) or carotid artery stenting (CAS) provides additional benefit beyond intensive medical management (IMM). This review examines the implications of the CREST-2 findings for carotid revascularisation strategies. Methodology The design, rationale and reported outcomes of CREST-2 were reviewed. Potential implications for patient selection, medical management and carotid revascularisation strategies were examined in the context of current evidence and contemporary clinical practice. Results CREST-2 represents the most contemporary evaluation of carotid revascularisation for asymptomatic carotid stenosis. The trial re-examines the benefit of both carotid endarterectomy and carotid artery stenting in the setting of intensive contemporary medical therapy. Carotid artery stenting plus intensive medical therapy reduced the incidence of the primary endpoint compared with intensive medical therapy alone, whereas carotid endarterectomy plus intensive medical therapy did not demonstrate a statistically significant benefit. Although not designed to directly compare revascularisation modalities, the divergent findings observed between the CAS and CEA arms challenge established assumptions regarding the management of asymptomatic carotid disease. Results emphasise the importance of intensive medical therapy, procedural risk and careful patient selection when considering intervention. Conclusions The CREST-2 findings are likely to influence contemporary treatment algorithms for asymptomatic carotid stenosis. While intensive medical therapy remains fundamental, the observed benefit associated with CAS raises important questions regarding the future role of endovascular intervention and the relative position of CEA within modern carotid practice.