Perioperative and Follow-Up TCAR Outcomes of a Single Institution

BACKGROUND: Transcarotid artery revascularization (TCAR) was developed to mitigate risks associated with both carotid endarterectomy and transfemoral carotid artery stenting. It is being performed in both high- and standard-risk patients. We report outcomes from the largest single-institution consecutive TCAR cohort to date. METHODS: A retrospective review was performed from a prospectively maintained database capturing all consecutive TCAR procedures performed across a large health system between September 2017 and May 2025. Demographics, perioperative variables, and short- and long-term outcomes were analyzed. A multivariable logistic regression was used to identify predictors of perioperative stroke or death within 30 days. RESULTS: A total of 1,000 TCAR procedures were performed by 23 surgeons. The mean age was 74 years. In all, 31% of patients presented with symptomatic stenosis. Technical success was achieved in 98%. Thirty-day stroke, death, and myocardial infarction occurred at 1.9%, 1.0%, and 0.2%, respectively, for a composite rate of 2.9%. The median length of stay was 1 day. At a mean follow-up of 18 months, ipsilateral stroke occurred in 3.4%, restenosis/reintervention in 1.7%, and all-cause mortality in 6.6%. Multivariable analysis identified prior stroke (odds ratio [OR] 2.4, P < 0.001) and chronic obstructive pulmonary disease (OR 1.7, P = 0.011) as independent predictors of perioperative stroke/death. Protective factors included clopidogrel use (OR 0.45, P = 0.014) and intraoperative administration of protamine (OR 0.47, P = 0.011). CONCLUSION: TCAR demonstrated high technical success, low perioperative morbidity, and favorable long-term outcomes in both high- and standard-risk patients. Optimal medical management and risk stratification by comorbidity and prior neurologic events improve outcomes. Randomized trials are needed to better define the roles of TCAR and carotid endarterectomy.