Contemporary outcomes of carotid revascularization procedures

Since the first carotid endarterectomy (CEA) in 1953 by Dr. Michael DeBakey, the management of carotid stenosis has evolved tremendously, with the introduction of transfemoral carotid artery stenting (tfCAS) in the 1990s and transcarotid artery revascularization (TCAR), introduced by Dr. Juan Parodi in 1998 and available commercially in 2015, as well as improved medical management. Society guidelines endorse revascularization for symptomatic patients with high-grade stenosis and acceptable procedural risk. Introduced as a minimally invasive alternative to CEA, tfCAS has been consistently associated with higher perioperative stroke risk compared with CEA. As such, guidelines recommend CEA for patients older than 70 years, although stenting may be considered for younger patients or those with high surgical risk. TCAR has increased in volume since its introduction in 2015, with continued growth after its coverage expansion in April 2022. Although no trials have directly compared TCAR with the other techniques, registry data have indicated its safety and equivocal outcomes compared with CEA, and guidelines show a preference for TCAR over tfCAS and CEA in patients with high surgical risk. Management of asymptomatic disease remains controversial, with advancements in medical therapy. The recent CREST-2 trial found a lower risk of perioperative stroke or death and ipsilateral stroke within 4 years after tfCAS and intensive medical therapy compared with intensive medical therapy alone; CEA and intensive medical therapy also had a lower risk but the difference did not reach statistical significance. As such, patient selection should continue to be individualized.