Comparative Safety and Efficacy of Transcarotid Artery Revascularization Versus Transfemoral Carotid Artery Stenting: A Systematic Review and Meta-Analysis.

BACKGROUND

Carotid artery stenosis is a significant cause of ischemic stroke. Transcarotid artery revascularization (TCAR), a newer technique using dynamic flow reversal, has emerged as a potentially safer alternative to transfemoral carotid artery stenting (TFCAS). This systematic review and meta-analysis aimed to compare TCAR and TFCAS in patients undergoing carotid revascularization.

METHODS

We searched PubMed, Cochrane CENTRAL, Scopus, and Web of Science through June 2025 for comparative studies evaluating TCAR versus TFCAS. The primary outcomes included 30-day and in-hospital mortality, stroke, and composite stroke/death. The secondary outcomes assessed myocardial infarction (MI), transient ischemic attack (TIA), procedural times, and periprocedural complications. Risk ratios (RRs) and mean differences were pooled using random-effects models.

RESULTS

Thirteen studies involving 142,032 patients were included in the analysis. TCAR significantly reduced 30-day mortality (RR 0.45; P < 0.001), in-hospital mortality (RR 0.45; P < 0.001), 30-day stroke (RR 0.66; P < 0.001), and composite 30-day stroke/death (RR 0.57; P < 0.001). TIA (RR 0.72; P < 0.001) and stroke/TIA (RR 0.66; P < 0.001) were also lower with TCAR. MI rates were similar overall, although asymptomatic patients had a higher 30-day MI risk with TCAR. TCAR reduced reperfusion injury (RR 0.38; P < 0.001) and hospital stay length (RR 0.76; P < 0.001) but had slightly longer operative times. Long-term data from 2 large cohorts confirmed TCAR's durable stroke risk reduction up to 3 years.

CONCLUSION

This meta-analysis of current observational data demonstrates that TCAR is associated with superior perioperative outcomes compared to TFCAS, with significantly lower rates of stroke and death. These findings support TCAR as a preferred endovascular treatment for eligible patients with carotid artery stenosis.