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Background Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are established revascularization strategies for carotid stenosis. While prior studies have focused on symptomatic patients, evidence in asymptomatic populations remains limited. Recent CREST-2 trial results suggest that CAS offers superior stroke prevention compared with medical therapy alone, whereas CEA did not meet this threshold. This study evaluates long-term outcomes of CAS versus CEA in adults with asymptomatic carotid stenosis.Methods Adults diagnosed with asymptomatic carotid stenosis who underwent CAS or CEA between January 2016 and December 2024 were identified from the TriNetX database using ICD-10 codes. Patients with a prior history of ischemic stroke, transient ischemic attack, or hemorrhage were excluded. Propensity-score matching (1:1) was performed based on demographics, comorbidities, and antithrombotic use, resulting in 6,238 patients per cohort. Primary outcomes were cerebral infarction and all-cause mortality at five years. Secondary outcomes included intraparenchymal hemorrhage and major bleeding events. Kaplan-Meier survival estimates and Cox proportional hazards models were used for comparisons.Results In the matched cohort, ischemic stroke occurred in 9.91% of CAS patients versus 9.49% of CEA patients, with higher cumulative event probability in the CAS group (16.22% vs 14.28%; HR 1.226, 95% CI 1.095-1.373, p<0.001). All-cause mortality was higher following CAS (cumulative probability 23.74% vs 20.35%; HR 1.217, 95% CI 1.098-1.349, p<0.001). Intraparenchymal hemorrhage was more common after CAS (cumulative probability 2.07% vs 1.35%; HR 1.673, 95% CI 1.166-2.400, p<0.01), while major bleeding rates were similar (cumulative probability 12.48% vs 12.45%; HR 1.088, 95% CI 0.961-1.232, p=0.183). Propensity matching achieved well-balanced cohorts across demographic and clinical variables.Conclusions In real-world practice, CAS for asymptomatic carotid stenosis demonstrates higher rates of ischemic stroke and mortality compared to CEA over five-year follow-up. In contrast to CREST-2, these real-world findings may still support CEA as the preferred revascularization strategy in appropriately selected patients.Disclosures L. Franco Castro: None. M.K. McIntyre: None. K. Jay: None. M. Khan: None. A. Malhotra: None. D. Lakhani: None. M. Colasurdo: None.