A large retrospective analysis of more than 350,000 patients drawn from the Vascular Quality Initiative (VQI) database found transcarotid artery revascularization (TCAR) maintained a more favorable neurological risk profile compared with carotid endarterectomy (CEA) in older symptomatic patients, with the advantage growing more pronounced as age increased.
The findings were presented at the 2026 Society for Clinical Vascular Surgery (SCVS) Annual Symposium in San Diego (March 28–April 1). “The question was, for the older population and those presenting with symptomatic carotid disease, which modality is better: TCAR or CEA,” said Faisal Aziz, MD, senior author on the study and chief of the division of vascular surgery at Penn State Health.
The researchers looked at 22 years of VQI data from 2003 to 2025, with patients stratified by their symptoms and age group. The study captured outcomes across more than 265,000 CEA patients and 93,000 TCAR patients.
Primary endpoints included postoperative stroke and mortality. Among symptomatic patients who underwent CEA, the overall risk of a neurological event was 2.6%, with that risk climbing as patient age increased.
Among TCAR patients, the rise in neurological risk with advancing age was minimal, and on adjusted analysis, TCAR was associated with significantly lower odds of postoperative neurological events compared with CEA.
The advantage was seen most among the oldest patients. “Both are acceptable options for treating patients with carotid disease,” said Aziz. “However, when dealing with patients 80 years or older who are symptomatic, it’s better to treat them with TCAR instead of CEA.”
The study’s scope and dataset size lend it particular weight in a field where evidence specific to elderly and symptomatic patients has historically been limited. The landmark NASCET trial established in the 1990s that surgical treatment cuts stroke risk dramatically in symptomatic patients, from roughly 25% with medical management alone to approximately 9% with CEA.
Yet which surgical approach is optimal for high-risk subgroups has remained less settled. The recently published CREST-2 trial focused exclusively on asymptomatic patients and did not include TCAR as a study arm, leaving a meaningful gap that this analysis addresses. “This study answers questions that were not answered in that trial,” said Aziz. “The true value of this study is for patients who are symptomatic.”
The large patient volume, while a product of retrospective registry design rather than randomization, is itself a meaningful strength of the analysis. “In looking at more than 350,000 patients, we found subtle differences which are very important,” said Aziz. “The patient volume is so high that we were able to get results which would not be possible with smaller sample sizes.”
The study offers practical direction for clinicians treating patients in this population. “It’s clinical judgment,” said Aziz. “We rely a lot on clinical judgment while making these decisions. It’s food for thought that for elderly patients who are presenting with symptoms of stroke, we should consider TCAR instead of endarterectomy if they’re deemed appropriate candidates based on their anatomy.”
Aziz pointed to the need for a prospective, randomized trial that would directly compare all three major approaches in the same study. “To date, we have no randomized controlled trial comparing TCAR with CEA or transfemoral carotid stenting,” said Aziz. “Hence the value of studies like this. They’re not level one evidence for randomized controlled trials, but they’re very powerful studies and they show the statistical difference between one and the other. The next step would be doing a randomized controlled trial and include TCAR, CEA and transfemoral stenting.”
