New study reveals TCAR outperforms TF-CAS for stroke prevention in carotid artery stenosis
Surgical transcarotid artery revascularisation (TCAR) demonstrated significantly lower stroke risk compared to percutaneous transfemoral carotid artery stenting (TF-CAS) over a 3-year follow-up period, according to a comprehensive comparative effectiveness study published in JAMA Network Open, offering critical guidance for physicians and patients selecting carotid stenting procedures.
A landmark comparative effectiveness study of carotid artery stenosis treatments has provided the first long-term data on stroke outcomes between two primary stenting techniques. The research, published in JAMA Network Open on 25 April 2025, followed nearly 10,000 patients who underwent either transcarotid artery revascularisation (TCAR) or transfemoral carotid artery stenting (TF-CAS), finding consistently lower stroke risk with TCAR among both asymptomatic and symptomatic patients during a 3-year follow-up period.
The study addresses a significant knowledge gap in the field of vascular surgery, as TCAR – despite being widely adopted across more than 600 US centres – has never been evaluated in a randomised clinical trial, while previous observational studies comparing TCAR and TF-CAS have been limited to periprocedural outcomes or shorter follow-up periods.
Filling a critical evidence gap
Led by Dr Jesse A. Columbo of Dartmouth-Hitchcock Medical Center and colleagues, this retrospective cohort study utilised data from the Vascular Implant Surveillance and Outcomes Network (VISION), a procedural registry linked to Medicare claims data. The researchers analysed outcomes for 5,798 asymptomatic patients and 4,721 symptomatic patients who underwent carotid stenting between October 2016 and December 2019.
“In the absence of longer-term results, the comparative stroke risk associated with these procedures remains undefined. This knowledge gap limits both clinicians and patients in their ability to make an informed decision regarding which procedure is better for durable stroke prevention,” the researchers noted, highlighting the importance of their work.
The researchers used a validated claims code method to identify strokes after hospital discharge, and applied multiple statistical approaches to ensure robust analysis, including propensity score matching and instrumental variable analysis to account for potential confounding factors.
TCAR shows superior outcomes across patient groups
The results demonstrated a clear advantage for TCAR over TF-CAS. Among asymptomatic patients, the 3-year stroke risk was 5.1% after TCAR compared to 9.2% after TF-CAS. For symptomatic patients, the difference was also significant: 16.6% for TCAR versus 20.9% for TF-CAS.
When adjusted for various clinical and demographic factors, the hazard ratio for stroke after TF-CAS compared to TCAR was 1.69 for asymptomatic patients and 1.42 for symptomatic patients, both statistically significant. This finding remained consistent across all sensitivity analyses.
Importantly, the research showed that the stroke risk difference was most pronounced within the first 30 days after the procedure, suggesting that procedural differences between the two techniques are a key factor.
Mortality and composite outcomes (stroke or death) also favoured TCAR. For asymptomatic patients, the 3-year mortality was 21.5% after TCAR versus 26.2% after TF-CAS, while the composite outcome was 22.6% for TCAR compared to 31.4% for TF-CAS. Similar advantages were observed in symptomatic patients.
Potential mechanisms behind TCAR’s advantage
The authors explained the potential mechanisms behind TCAR’s superiority: “There are 2 primary mechanisms that may explain the observed decreased stroke risk associated with TCAR compared with TF-CAS. The divergence in the risk of stroke between the 2 procedures primarily appeared in the periprocedural period, which suggests that there are significant risk differences in the conduct of the 2 stenting procedures, rather than longer term.”
They added: “TCAR is performed via a low-neck incision with direct carotid artery access, obviating the need to traverse the aortic arch that is required with TF-CAS, which may be a risk factor for embolic stroke. In addition, TCAR is performed using flow-reversal for embolic protection, which can be initiated before manipulation of the carotid lesion.”
By contrast, TF-CAS uses distal filter embolic protection, requiring operators to cross the carotid lesion before filter deployment – a manoeuvre potentially associated with stroke risk.
Clinical practice versus trial results
An important observation from the study was that the observed stroke and mortality risks were higher than those reported in previous randomised clinical trials (RCTs) of TF-CAS. The authors suggest this reflects the reality of everyday clinical practice versus the highly controlled environment of clinical trials.
“Results from clinical practice studies, such as this one, can offer a complementary perspective to the results of RCTs, documenting how the procedures may perform once they are in widespread use,” they noted. “The higher stroke and mortality risks we report provide the sobering view that carotid stenting procedures may not perform as well in clinical practice as may be anticipated on the basis of the results of RCTs.”
This observation is particularly relevant given recent changes in US regulatory oversight. In October 2023, the Centers for Medicare & Medicaid Services (CMS) expanded coverage for carotid artery stenting and removed the strict federal oversight of quality and outcome benchmarks that had been maintained since 2005, transferring this responsibility to individual institutions.
Implications for clinical practice
The authors emphasised the timeliness of their findings: “In the absence of an RCT, these data represent important findings to inform future procedure choices for patients considering carotid stenting and add to the growing body of literature to support the growing role of TCAR in the treatment of carotid artery stenosis.”
The researchers concluded: “In this comparative effectiveness study, TCAR was associated with a lower risk of stroke than TF-CAS. This finding was consistent in both asymptomatic and symptomatic patients and durable over a 3-year interval. These findings can inform procedure choices for patients considering carotid artery stenting.”
Given that there are no completed or enrolling randomised clinical trials evaluating TCAR against other methods, these comparative stroke risk results provide valuable evidence to guide clinicians and patients in selecting the most appropriate carotid stenting approach.
While acknowledging limitations inherent to observational research, the authors conducted multiple sensitivity analyses with consistent results. The study’s use of Medicare-linked data may limit generalisability to non-Medicare populations, but the large sample size and rigorous methodology strengthen the reliability of the findings.
Reference
Columbo, J. A., Martinez-Camblor, P., Stone, D. H., et. al. (2025). Effectiveness of transcarotid vs transfemoral carotid stenting for stroke prevention. JAMA Network Open, 8(4), e259143. https://doi.org/10.1001/jamanetworkopen.2025.9143
