Carotid endarterectomy (CEA) and transcarotid artery revascularization (TCAR) showed similar perioperative safety and long-term effectiveness in patients with severe cardiac comorbidities, according to a recent retrospective review of a prospectively maintained database.
Aidin Baghbani, MD, first author on the study and an integrated vascular surgery resident at the University of Texas Health Science Center at Houston, said the study was designed to address a common clinical dilemma. “CEA has long been considered the gold standard for stroke prevention,” he said. “But in patients with markedly reduced ejection fraction [EF] or persistent arrhythmia, surgeons often worry about perioperative cardiac complications and may potentially choose TCAR.”
TCAR is often seen as less physiologically stressful due to its minimally invasive approach and smaller incision, but Baghbani said there is a lack of comparative data in this specific population. “The primary objective of our study was to compare perioperative and long-term outcomes of CEA versus TCAR in patients with significant cardiac comorbidities, defined as low ejection fraction — less than 30% — and/or persistent arrhythmia,” he said.
The study examined patients with severe carotid artery disease who were considered high cardiac risk and underwent CEA or TCAR between December 2015 and August 2025. The data were presented at the 2026 annual winter meeting of the Vascular and Endovascular Surgery Society (VESS) in Olympic Valley, California (Feb. 2-8).
Findings from the study showed no significant difference in major outcomes between the two approaches. While TCAR patients tended to be older and more likely to have coronary artery disease, chronic obstructive pulmonary disease, and anticoagulation use, rates of perioperative stroke, myocardial infarction, and 30-day mortality were similar between the groups. Long-term survival and stroke-free survival also did not differ.
Baghbani said the findings support an individualized approach to treatment selection. “Our data suggests significant cardiac comorbidity should not automatically exclude patients from undergoing CEA, provided they are otherwise appropriate surgical candidates,” he said. “At the same time, TCAR remains an excellent option, particularly in patients where minimizing blood loss, cranial nerve injury, or physiological stress is a priority. Instead of asking if the patient is too high risk for CEA, the better question may be which procedure best fits the patient’s anatomy, comorbidities, and the institution’s expertise.”
The study also provides data that can help support shared decision-making. “When counseling a patient with low EF or persistent arrhythmia, surgeons can explain that in a large cohort, stroke, heart attack, and survival outcomes were similar between CEA and TCAR,” said Baghbani. “That allows discussions to shift toward patient-specific priorities, such as recovery expectations or concerns about nerve injury, bleeding risk or prior neck surgery, rather than fear-driven decision-making. This empowers shared decision-making by replacing assumptions about high-risk with evidence-based reassurance.
