Across more than 1,000 transcarotid artery revascularization (TCAR) procedures performed over eight years at a single high-volume institution, a recent study found only 12 patients required reintervention — a 1.1% rate that speaks to the durability of TCAR. The data also showed those reinterventions had a 100% technical success rate that speaks equally to the capacity of experienced teams to manage failure when it does occur.
TCAR received FDA approval in 2015 and has since seen rapid adoption for managing carotid artery stenosis, particularly in patients at elevated surgical risk. While its outcomes are well reported, data on what happens when TCAR fails and how best to address it has remained limited. The current study was designed to fill that gap, providing one of the largest single-center analyses of post-TCAR reintervention to date.
“TCAR has been increasingly utilized in the management of carotid artery disease and it’s important for physicians to understand how to manage TCAR failure during follow-up,” said Venkata Vineeth Vaddavalli, MBBS, MS, a vascular surgery resident in the Department of Cardiothoracic and Vascular Surgery at the University of Texas Health Science Center at Houston, who presented the study during Plenary Session 3 at VAM 2026. “We retrospectively reviewed the indications for reintervention and the management strategies used on a case-by-case basis.”
The 1,086-patient cohort was medically complex, with comorbidities including coronary artery disease in 44%, diabetes mellitus in 45.1% and active smoking in 18.4%. Median age was 74.8 years and 30.7% of patients were symptomatic preoperatively. Technical success of TCAR reached 98.3%, with 30-day rates of ipsilateral stroke, myocardial infarction and mortality of 1.7%, 0.3% and 0.8%, respectively. Freedom from ipsilateral stroke at one, three and five years was 97.6%, 96.4% and 95.9% and overall survival at those intervals was 96.1%, 92.6% and 90.3%.
Among the 12 patients who required reintervention, in-stent restenosis greater than 70% was the most common indication, accounting for eight cases. The remaining cases involved common carotid artery stenosis proximal to a patent stent, a crushed stent and dissection causing stent stenosis. Two-thirds of reinterventions were managed endovascularly. All 12 reintervention cases were technically successful. “The reintervention rate after TCAR is low and reinterventions can be managed successfully either with open or endovascular techniques based on individual anatomy and risk factors,” said Vaddavalli.
Vaddavalli said the results make a clear case for flexibility over protocol. Both endovascular and open strategies produced good outcomes when matched to each patient’s anatomy and risk profile and the study found no single technique universally superior — a finding that reinforces the value of a well-rounded technical skill set at centers where TCAR is regularly performed.
“Although the rate of reintervention is very low, the increasing number of TCAR procedures being performed highlights the importance for physicians at high-volume and tertiary care centers to be familiar with techniques for managing failed TCARs,” said Vaddavalli.
Beyond technical management, the study points to the role of patient compliance in sustaining TCAR’s long-term benefits. Smoking cessation, antiplatelet therapy and statin regimens are cited as essential to durable outcomes. These factors require ongoing reinforcement well after the index procedure.
Vaddavalli said that due to there being only 12 reintervention cases across the cohort, drawing firm conclusions about specific risk factors for restenosis was not possible. The low event rate, while itself a reflection of TCAR’s effectiveness, constrained the statistical analysis. “We would like to direct future research toward identifying the risk factors associated with restenosis and reintervention following TCAR,” he said. “Future multi-institutional studies or studies with larger cohorts may help further delineate these risk factors.”
For centers where TCAR volume continues to grow, the study offers both reassurance and a practical charge: Understand the procedure’s failure modes and be prepared to manage them. “Performing TCAR in patients with suitable anatomy according to the instructions for use is associated with good long-term outcomes and only a small proportion of patients require reintervention during follow-up,” said Vaddavalli.
