Carotid endarterectomy (CEA) was associated with significantly lower long-term stroke and mortality compared to carotid artery stenting (CAS) in patients with asymptomatic carotid artery disease, according to a new real-world analysis.
The study, which was presented at VAM 2026, compared outcomes between patients undergoing CEA and CAS for asymptomatic carotid stenosis and evaluated stroke, mortality and the combined outcome of stroke or death at multiple time points extending to five years.
Data was gathered from TriNetX, a large, international electronic health record data set that aggregates longitudinal real-world data from multiple institutions. The study included more than 100,000 patients with asymptomatic carotid artery disease who underwent either CEA or CAS between January 2005 and January 2025 in the United States. To reduce treatment bias, investigators performed a one-to-one propensity score–matched analysis.
“The key finding in our study was that CEA consistently demonstrated lower stroke rates compared to CAS at every time point,” said Anthony Chau, MD, senior author on the study. “Additionally, the composite outcome of stroke or death significantly favored CEA at all the time intervals.”
While early outcomes were similar between procedures, CEA demonstrated a statistically significant survival benefit at three years. “Overall, the data suggests a more durable long-term advantage of CEA over CAS in asymptomatic patients,” said Chau.
Chau said the results suggest procedural choice may have important implications well beyond the perioperative period. “Our findings suggest that in appropriately selected asymptomatic patients, CEA may be the preferred intervention when we consider long-term stroke prevention and survival as our primary goals,” he said. “Although perioperative outcomes may be relatively comparable, the divergence in outcomes over time indicates that the procedural choice actually has very meaningful long-term consequences.”
According to Chau, the findings may also help inform conversations with patients when deciding between treatment options. “When counseling patients, it’s really important to emphasize that while both procedures are overall safe in the short term, CEA appears to offer a small yet consistent long-term benefit in reducing stroke risk and improving survival,” he said. “This allows for more nuanced discussion that balances short-term recovery considerations with long-term outcomes.”
While the TriNetX database allows for greater capture of long-term outcomes data, Chau said that it does not give as much detail on procedural precision like the Vascular Quality Initiative (VQI). That’s why one of the study’s key limitations is that the CAS cohort included both transfemoral and transcarotid stenting approaches, which Chau said could influence outcomes and may not reflect results of either procedure in isolation.
The study reflects broader real-world outcomes across a large patient population, which Chau said may complement findings from randomized trials. “While clinical trials provide level one evidence, they’re fairly highly selected,” he said. “It’s hard to generalize clinical trial data to real-world practice. But our data suggests that when we’re optimizing patient selection for CEA versus CAS, CEA could really improve long-term neurologic and survival outcomes at the population level.”
He added that the data support continued refinement of guidelines and shared decision-making strategies as clinicians weigh intervention choices. “In asymptomatic carotid disease, CEA does provide a consistent and meaningful long-term advantage over CAS in reducing both stroke and improving survival,” said Chau. “Despite some similar short-term outcomes, the long-term outcomes are where it really diverges.”
