Purpose Recent reports from ECST-2 and CREST-2 have prompted renewed discussion regarding the role of carotid revascularisation in the era of increasingly effective medical therapy and lower baseline stroke risk. We sought to examine how these trials should be interpreted together to inform contemporary clinical decision-making. Methodology A structured narrative comparison of ECST-2 and CREST-2 was undertaken using published eligibility criteria, study design and primary outcomes. Analysis focused on how differences in patient selection, endpoint composition and follow-up duration influence the clinical conclusions that can be drawn. Results ECST-2 enrolled patients with asymptomatic or low-to-intermediate-risk symptomatic carotid stenosis using the Carotid Artery Risk (CAR) score. Participants were randomised to optimised medical therapy (OMT) alone or OMT plus revascularisation (CEA or CAS). In its interim analysis, ECST-2 found no overall advantage for revascularisation using a hierarchical composite endpoint that included peri-procedural events and silent cerebral infarction over 2 years. CREST-2 enrolled patients with high-grade asymptomatic carotid stenosis and compared intensive medical management alone with intensive medical management plus CEA or CAS in parallel trials. Reported results to 4 years show no clear benefit for CEA over medical therapy, while CAS demonstrated a signal of benefit on the composite endpoint, driven by fewer ipsilateral strokes. Conclusion ECST-2 and CREST-2 address related but distinct clinical questions, with differing conclusions explained by differences in baseline risk, endpoint composition, and duration of follow-up. Interpreted together, these trials support a shift away from stenosis severity alone toward risk-based patient selection, with revascularisation reserved for carefully selected patients most likely to derive long-term benefit.