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Background Carotid web (CaW) is an underrecognized cause of ischemic stroke associated with a high risk of recurrence. The optimal approach for secondary prevention remains uncertain.Methods We retrospectively analyzed a prospectively maintained dual-center cohort of patients with symptomatic CaW treated between 2014 and 2025, comparing both approaches: carotid artery stenting (CAS) and medical management (MM) at discharge. MM included single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), or anticoagulation at discharge. The primary outcome was recurrent ischemic stroke or transient ischemic attack (TIA). Event rates were calculated per 100 person-years with 95% confidence intervals. Kaplan-Meier analysis assessed cumulative incidence, and time-dependent Cox models accounted for treatment crossover.Results A total of 136 patients with 137 symptomatic CaW were included. Overall, 50 lesions were treated with CAS and 88 with MM. The MM strategy included SAPT (44.3%), DAPT (45.5%), anticoagulation (6.8%), or SAPT plus anticoagulation (3.4%). In the CAS group, patients received DAPT for 3 months followed by SAPT, except one on aspirin plus anticoagulant. Baseline comorbidities were similar between groups, including hypertension (56% vs 56%, p=0.99), diabetes mellitus (14% vs 17%, p=0.64), dyslipidemia (31% vs 22%, p=0.33), atrial fibrillation (2% vs 2%, p=0.95), current smoking (10% vs 19%, p=0.17), and obesity (34% vs 36%, p=0.81). Median exposure time was longer with CAS (35.6 vs 12.5 months). Follow-up rates were higher in the CAS group, with 82% vs 68% at ≥3 months, 78% vs 62% at ≥6 months, 66% vs 51% at ≥1 year, and 58% vs 37% at ≥2 years vs MM. During follow-up, 16 recurrent events occurred in the MM group (15 ischemic strokes—all large vessel occlusions—and 1 TIA) with 75% receiving DAPT and 25% SAPT at discharge, with no events in patients under anticoagulation. Median time to recurrence was 234 days (IQR 5-370), with 31% within 30 days. No recurrent strokes occurred in the CAS group. Five MM patients underwent subsequent stenting after recurrence. Incidence rates were 5.69 per 100 person-years (95% CI 3.25-9.24) for MM and 0.0 (95% CI 0.0-1.93) for CAS. In time-dependent Cox analysis, CAS was associated with a lower risk of recurrent events ( figure 1).Conclusions In this study, CAS was associated with a lower risk of recurrent ischemic stroke compared with MM approach. Randomized data is warranted.Disclosures S. Batista: None. F. Nahab: None. J. Dolia: None. A. Alqudah: None. S. Yelam: None. M. Frankel: None. G. Mohamed: None. J. Allen: None. D. Haussen: None.Abstract E-217 Figure 1