This review shows that TCAR is not just another carotid stenting technique, but a potentially safer endovascular strategy with a recurrent signal for lower stroke and death risk than transfemoral CAS, especially when neuroprotection matters most. The full read is worth it because it clarifies where that advantage looks strongest, where the evidence is still mixed, and which anatomical, symptomatic, and restenotic subgroups may truly benefit from TCAR.
Abstract: To synthesize contemporary evidence comparing the perioperative and long-term outcomes of TCAR versus CAS in patients with carotid artery disease. The review utilises 37 original studies with 1685306 total participants (topic deduplicated ΣN). The evidence map consistently indicates that TCAR is associated with safer neurologic outcomes than transfemoral CAS, with perioperative stroke/death reported as 1.6% versus 2.9% in one large registry comparison and 1.6% versus 5.2% when compared with transfemoral stenting using distal embolic protection. Longer-term signals also favored TCAR, including lower 3-year stroke risk in asymptomatic patients (5.1% vs 9.2%) and symptomatic patients (16.6% vs 20.9%). Across the mapped literature, this advantage appears biologically plausible because studies comparing protection strategies suggest that direct carotid access with dynamic flow reversal may provide better neuroprotection than conventional transfemoral approaches and distal filters. Clinically, these findings support TCAR as the preferred endovascular option when carotid revascularization is needed but CEA is less suitable, while also underscoring the importance of anatomy, lesion calcification, and postoperative hemodynamic management in patient selection. Because the current evidence base is largely retrospective and heterogeneous across CAS techniques, the next priority is prospective head-to-head evaluation that standardizes comparator strategy and clarifies which symptomatic, restenotic, and anatomically complex subgroups derive the greatest benefit from TCAR.
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Final search date and database lock: 2026-04-02 13:01:42 CEST
Plan: Pro (expanded craft tokens; source: PubMed)
Source: PubMed
Total Abstracts/Papers: 80
Downloaded Abstracts/Papers: 80
Included original and non-original Abstracts/Papers (all): 41
Included original Abstracts/Papers (Vote counting by direction of effect): 37
Reference Index (links used in paper): 24
Total participants (topic deduplicated ΣN): 1685306
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[7] Transcarotid artery revascularization is associated with similar outcomes to carotid endarterectomy regardless of patient risk status. — https://doi.org/10.1016/j.jvs.2022.03.860
[9] Comparative safety and efficacy of invasive therapies for carotid artery stenosis: a systematic review and network meta-analysis. — https://doi.org/10.1136/jnis-2025-023900
[10] Cerebral Hyperperfusion Syndrome Risk Comparison between Transcarotid Artery Revascularization and Carotid Artery Stenting with Distal Embolic Protection. — https://doi.org/10.1016/j.avsg.2024.12.064
[12] Outcomes following carotid revascularization in patients with prior ipsilateral carotid artery stenting in the Vascular Quality Initiative. — https://doi.org/10.1016/j.jvs.2024.08.024
[13] Association of stroke or death with severity of carotid lesion calcification in patients undergoing carotid artery stenting. — https://doi.org/10.1016/j.jvs.2023.10.046
[14] Procedural Safety Comparison Between Transcarotid Artery Revascularization, Carotid Endarterectomy, and Carotid Stenting: Perioperative and 1-Year Rates of Stroke or Death. — https://doi.org/10.1161/jaha.121.024964
[15] Seven years of the transcarotid artery revascularization surveillance project, comparison to transfemoral stenting and endarterectomy. — https://doi.org/10.1016/j.jvs.2024.05.048
[17] Regional variation in patient selection, practice patterns, and outcomes based on techniques for carotid artery revascularization in the Vascular Quality Initiative. — https://doi.org/10.1016/j.jvs.2023.05.029
[19] Systematic Review of Length of Stay After Carotid Endarterectomy and Carotid Artery Stenting. — https://doi.org/10.62713/aic.4124
[20] A Contemporary Evaluation of the Centers for Medicare and Medicaid Services High-risk Indicators for Carotid Endarterectomy. — https://doi.org/10.1097/sla.0000000000006397
[21] Hemodynamic instability predicts in-hospital and 1-year mortality after transcarotid artery revascularization and transfemoral carotid stenting. — https://doi.org/10.1016/j.jvs.2023.03.035
[24] Optimal periprocedural antithrombotic treatment in carotid interventions: An international, multispecialty, expert review and position statement. — https://doi.org/10.1016/j.pcad.2022.10.002
[29] In-hospital outcomes after upper extremity versus transfemoral and transcarotid access for carotid stenting in the Vascular Quality Initiative. — https://doi.org/10.1016/j.jvs.2022.05.030
[32] Risk factors and impact of postoperative hypotension after carotid artery stenting in the Vascular Quality Initiative. — https://doi.org/10.1016/j.jvs.2020.06.116
[35] The elevated stroke and death rates among asymptomatic patients undergoing carotid stenting in the Pacific Northwest are associated with high-risk patient selection. — https://doi.org/10.1016/j.jvs.2024.12.006
