An update on the management of symptomatic extracranial carotid artery stenosis, CEA vs. TFCAS vs. TCAR

The management of patients with significant carotid stenosis has been somewhat controversial. This update is a review article on the management of significant carotid stenosis in role of carotid endarterectomy (CEA) vs. transfemoral carotid artery stenting (TFCAS) vs. transcarotid artery revascularization (TCAR). A systemic review and meta-analysis was conducted by the Mayo Clinic Evidence Practice Center on behalf of the Society for Vascular Surgery for their 2022 carotid guidelines. The two commonly quoted randomized trials comparing medical therapy vs. CEA for symptomatic >50% and >70% stenosis, both North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) showed superiority of CEA with best medical therapy vs. best medical therapy. The NASCET showed relative risk stroke reduction of 65% and absolute risk reduction of 17% at two years for those with ≥70% carotid stenosis. Similar findings were also found on ECST. Pooled analysis of the four commonly quoted randomized trials compared CEA vs. TFCAS in treating patients with >50% carotid stenosis who are standard risk for CEA showed superiority of CEA 30-day rate of stroke/death with relative risk reduction of 0.68. Long-term data of these trials, with a median follow-up 2-6.9 years showed risk of stroke/death within 120 days was significantly better for CEA vs. CAS (5.5% vs. 8.7%). After which there was no differences in the annual rate of late ipsilateral stroke. A meta-analysis of the four commonly quoted randomized trials showed that the five-year risk of any stroke favoring CEA over stenting with relative risk of 0.79. However, real world data for TFCAS was not encouraging. More recently, TCAR procedure showed very satisfactory results of perioperative stroke/death, superior to TFCAS and equivalent to CEA. Long-term data is needed. CEA is preferred over TFCAS in symptomatic patients with ≥50% stenosis. TCAR is preferred over CEA in the presence of anatomical/physiological comorbidities. TFCAS is preferred in patients with severe uncorrectable CAD, CHF, or COPD.