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Tcar Maintains Favorable Risk Profile Compared With Cea In Elderly And Symptomatic Patients
Aditya Safaya, MD, FACS, Ahsan Zil-E-Ali, MD, MPH, Kristine L. So, MD, FACS, Faisal Aziz, MD, MBA, FACS, DFSVS.
Pennsylvania State University College of Medicine, Hershey, PA, USA.
Objectives: Carotid endarterectomy (CEA) and transcarotid artery revascularization (TCAR) are established options for carotid revascularization, but the optimal procedure may vary by age and symptom status. We compared postoperative neurological events (stroke/TIA) and 30-day mortality after CEA and TCAR across age and symptom strata.
Methods: We analyzed patients undergoing CEA or TCAR in the Vascular Quality Initiative (VQI) registry between 2003-2025. Patients were stratified by symptom status, defined as ipsilateral stroke, TIA, or amaurosis fugax within six months, and by age group (50-60, 61-70, 71-80, ≥80 years). Primary outcomes were postoperative neurological events (stroke/TIA) and 30-day all-cause mortality. Outcomes were compared with chi-square testing. Multivariable logistic regression adjusting for demographic and clinical covariates (sex, hypertension, diabetes, coronary artery disease, chronic kidney disease, smoking, and procedure urgency) estimated the independent association of age and procedure type with outcomes.
Results: A total of 265,574 CEA patients (symptomatic n=6,135; asymptomatic n=259,439) and 92,708 TCAR patients (symptomatic n=37,659; asymptomatic n=55,049) were analyzed. In symptomatic CEA patients, neurological events occurred in 157 (2.6%, p=0.44) and mortality in 78 (1.3%), rising from 0.4% at 50-60 years to 2.2% at ≥80 years (p=0.001). In asymptomatic CEA patients, neurological events occurred in 4,151 (1.6%) and mortality in 1,761 (0.7%), both increasing with age (p<0.001). In symptomatic TCAR patients, neurological events occurred in 967 (2.6%) and mortality in 383 (1.0%), both rising significantly with age (p<0.001). In asymptomatic TCAR patients, neurological events occurred in 696 (1.3%, p=0.003) and mortality in 268 (0.5%), with only a modest increase by age (p=0.057). On adjusted analysis, age ≥80 years was independently associated with higher 30-day mortality across both procedures (OR 2.1, 95% CI 1.7-2.5, p<0.001), while among symptomatic patients aged ≥80 years, TCAR was associated with significantly lower odds of postoperative neurological events compared with CEA (OR 0.72, 95% CI 0.58-0.88, p=0.002).
Conclusions: Advancing age was associated with increased risk of stroke/TIA and 30-day mortality after both CEA and TCAR. In symptomatic elderly patients, particularly those ≥80 years, TCAR was independently associated with lower odds of perioperative neurological events compared with CEA. These findings highlight the importance of tailoring carotid revascularization strategies by age and symptom status and suggest that TCAR may represent the safer alternative for elderly, high-risk patients.
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