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Background The findings of CREST2 suggested a small but measurable benefit to carotid artery stenting (CAS) over intensive medical management (IMM) in reducing morbidity and no benefit to carotid endarterectomy (CEA) over IMM. The modern cost effectiveness of these interventions is unknown.Methods We developed a probabilistic cohort state-transition model to evaluate the cost-effectiveness of four management strategies for patients with high-grade asymptomatic carotid stenosis based on the cohorts in CREST2: carotid endarterectomy (CEA), carotid artery stenting (CAS), and their respective medical management comparison groups (IMM-CEA, IMM-CAS). In revascularization strategies, the procedure was modeled as occurring prior to model entry, with costs and outcomes tracked over a 4-year horizon. Model inputs were derived from published literature and clinical trial data. The analysis was conducted from the health system perspective. Both costs and health outcomes were discounted at an annual rate of 3%. Probabilistic sensitivity analysis was performed to assess the robustness of findings across model assumptions.Results In the base-case analysis, CAS yielded the highest quality-adjusted life-years (QALYs) at 3.14 but also the highest total cost ($58,281), while IMM-CAS was the least costly strategy ($46,394) with the fewest QALYs (3.06). CEA produced 3.13 QALYs at a total cost of $56,215, and IMM-CEA yielded 3.10 QALYs at $46,480. No strategy was strictly dominated. The incremental cost-effectiveness ratio for CEA versus IMM-CEA was $264,883/QALY, and for CAS versus IMM-CAS was $151,242/QALY. Probabilistic sensitivity analysis demonstrated that IMM was the cost-effective strategy in 78.1% of simulations at a willingness-to-pay threshold of $100,000/QALY.Discussion Intensive medical management represented the most cost effective strategy for management of asymptomatic carotid stenosis over the four year time horizon, with CAS and CEA offering minimally superior total QALY at substantially increased average cost, failing to meet the $50,000 and $100,000/QALY willingness-to-pay threshold. These findings may vary among subgroups and along a protracted time horizon.Disclosures J. Feler: None. S. Lin: None. E. Shaaya: None. R. Torabi: None. K. Moldovan: None. R. Sastry: None.Abstract E-241 Figure 1