Outcomes of Carotid Endarterectomy Versus Transcarotid Artery Revascularization in Patients with Significant Cardiac Comorbidities.

INTRODUCTION: Patients with left ventricular ejection fraction (LVEF) <30% or persistent arrhythmia are often considered at elevated risk for carotid revascularization. While carotid endarterectomy (CEA) remains standard, transcarotid artery revascularization (TCAR) has emerged as a less invasive alternative. Comparative outcomes between these procedures in high-risk cardiac patients remain poorly defined. METHODS: A retrospective review of a prospectively maintained database identified all CEA and TCAR procedures performed between December 2015 and August 2025. High cardiac risk was defined as LVEF <30% and/or persistent arrhythmia. Baseline demographics, perioperative variables, and outcomes were compared using stratified and survival analyses. RESULTS: Among 2,466 patients, 405 (16.4%) met high-risk criteria (CEA: n=200; TCAR: n=205). Compared with low-risk patients, the high-risk cohort was older (75.4 vs. 71.7 years, p<0.01) and had higher rates of coronary artery disease (64.4% vs. 42.0%, p<0.01) and anticoagulant use (39.4% vs. 5.6%, p<0.01). Blood loss was greater with CEA than TCAR (50 vs. 25 mL, p<0.01) but similar across risk groups. Among high-risk patients, perioperative ipsilateral stroke (2.0% vs. 3.4%), myocardial infarction (4.0% vs. 3.4%), and 30-day mortality (3.0% vs. 2.4%) did not differ between CEA and TCAR. Median follow-up was 20 months after CEA and 11 months after TCAR, with no difference in long-term survival or stroke-free outcomes (Gray's test p=0.35). CONCLUSIONS: In patients with severe cardiac comorbidities, CEA and TCAR offer comparable perioperative and long-term results. Both represent safe and durable options for carotid revascularization in this high-risk population.