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1.1 Guidelines
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• No. 86: For patients undergoing carotid artery stenting, post-dilation is not
recommended when the residual stenosis is <30%, in order to reduce haemodynamic instability.
• No. 128: For patients presenting with a vertebrobasilar territory transient isch-
aemic attack or stroke and a 50–99% vertebral artery stenosis, routine stenting is
not recommended.
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1.1.2 European Stroke Organisation Guideline
onEndarterectomy andStenting forCarotid Artery
Stenosis [2]
• In patients with ≥60% asymptomatic carotid artery stenosis considered to be at
increased risk of stroke on best medical therapy alone, we recommend carotid
endarterectomy. Quality of evidence: Moderate; Strength of recommendation:
Strong for carotid endarterectomy. (This recommendation is independent of sex
and stenosis severity).
• In patients with asymptomatic carotid stenosis in whom revascularisation is con-
sidered to be appropriate, we suggest endarterectomy as the current treatment of
choice. Quality of evidence: Moderate; Strength of recommendation: Weak for
carotid endarterectomy.
• In patients with severe (70–99%) symptomatic carotid artery stenosis, we recom-
mend carotid endarterectomy. Quality of evidence: High; Strength of recommendation: Strong for carotid endarterectomy.
• In patients with moderate (50–69%) symptomatic carotid artery stenosis, we
suggest carotid endarterectomy. Quality of evidence: Low; Strength of recommendation: Weak for carotid endarterectomy.
• In patients with symptomatic carotid artery stenosis requiring revascularisation,
we recommend endarterectomy as the treatment of choice. Quality of evidence:
Moderate; Strength of recommendation: Strong for carotid endarterectomy.
• In patients with symptomatic carotid stenosis <70years old requiring revascu-
larisation, we suggest that stenting may be considered as an alternative to endarterectomy. Quality of evidence: Low; Strength of recommendation: Weak for
carotid stenting.
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1 Extracranial Carotid Stenosis
1.1.3 Society forVascular Surgery Clinical Practice Guidelines
forManagement ofExtracranial Cerebrovascular
Disease [3]
• For low surgical risk patients with asymptomatic carotid bifurcation atheroscle-
rosis and stenosis of >70% (documented by validated duplex ultrasound or CTA/
angiography), we recommend CEA with best medical therapy instead of maximal medical therapy alone for the long-term prevention of stroke and death.
Level of recommendation: grade 1 (strong); quality of evidence: B (moderate).
• We recommend CEA over TF (transfemoral)-carotid artery stenting (CAS) in
low- and standard-risk patients with >50% symptomatic carotid artery stenosis.
Level of recommendation: grade 1 (strong); quality of evidence: A (high).
• In patients with recent stable stroke (modied Rankin scale score 0–2), we rec-
ommend carotid revascularization for symptomatic patients with >50% stenosis
to be performed as soon as the patient is neurologically stable after 48h but denitely before 14days after the onset of symptoms. Level of recommendation:
grade 1 (strong); quality of evidence: B (moderate).
• In patients undergoing revascularization within the rst 14days after the onset of
symptoms, we recommend CEA rather than carotid stenting. Level of recommendation: grade 1 (strong); quality of evidence: B (moderate).
• We recommend against revascularization, regardless of the extent of stenosis for
patients who experienced a disabling stroke, have a modied Rankin scale score
of ≥3, whose area of infarction is >30% of the ipsilateral middle cerebral artery
territory, or who have altered consciousness to minimize the risk of postoperative
parenchymal hemorrhage. These patients can be reevaluated for revascularization later if their neurologic recovery is satisfactory. Level of recommendation:
grade 1 (strong); quality of evidence: C (low).
• We recommend against routine screening for clinically asymptomatic carotid
artery stenosis in individuals without cerebrovascular symptoms or signicant
risk factors for carotid artery disease. Level of recommendation: grade 1 (strong);
quality of evidence: B (moderate).
• In selected asymptomatic patients who are at an increased risk of carotid steno-
sis, we suggest screening for clinically asymptomatic carotid artery stenosis,
especially if patients are willing to consider carotid intervention if signicant
stenosis is discovered. Level of recommendation: grade 2 (weak); quality of evidence: B (moderate).
• In asymptomatic patients who are undergoing screening for carotid artery steno-
sis, we recommend duplex ultrasound performed in an accredited vascular laboratory as the imaging modality of choice instead of CTA, MRA, or other imaging
modalities. Level of recommendation: grade 1 (strong); quality of evidence: B
(moderate).
• For patients with symptomatic carotid stenosis of 50% to 99%, who require both
CEA and CABG, we suggest CEA before, or concomitant with, CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the interven-
1.2 Results
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tion depends on the clinical presentation and institutional experience. Level of
recommendation: grade 2 (weak); quality of evidence: C (low).
• In patients with severe (70%–99%) bilateral asymptomatic carotid stenosis or
severe asymptomatic stenosis and contralateral occlusion, we suggest CEA
before, or concomitant with, CABG.Level of recommendation: grade 2 (weak);
quality of evidence: C (low).
• In patients requiring carotid intervention, staged or synchronous with coronary
intervention, we suggest that the decision between CEA and CAS be determined
by the timing of procedure, the need for anticoagulation or antiplatelet therapy,
patient anatomy, and patient characteristics. Level of recommendation: grade 2
(weak); quality of evidence: B (moderate).
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1.2 Results
1.2.1 Randomised Trials
1.2.1.1 Carotid Endarterectomy or Stenting or Best Medical Treatment
SPACE-2 is the rst randomised controlled trial to present data directly comparing
CEA plus BMT, CAS plus BMT, and BMT alone as treatment modalities for asymptomatic carotid stenosis [4]. 513 patients across SPACE-2, SPACE-2a, and
SPACE-2b were recruited and surveyed between July 9, 2009, and Dec 12, 2019, of
whom 203 (40%) were allocated to CEA plus BMT, 197 (38%) to CAS plus BMT,
and 113 (22%) to BMT alone. Median follow-up was 59·9months. A risk reduction
with adequate BMT, known from registry data, was also shown in SPACE-2.
Superiority of CEA plus BMT or CAS plus BMT over BMT alone could not be
shown in the 5-year follow-up period, although CEA showed a stable postprocedural period. Because of the small sample size, results should be interpreted with
caution.
1.2.1.2 CEA andCAS inAsymptomatic Carotid Stenosis
The ACST-2 Trial [5] is a randomised multicentre trial in which a total of 3625
patients with asymptomatic carotid stenosis were assigned to either CEA (n=1814)
or CAS (n=1811), with good medical treatment and a median follow-up of 5years.
Overall, 1% of patients developed a disabling stroke periprocedurally (15in CAS
and 18in CEA) and 2% developed a non-disabling stroke (48in CAS and 29 in
CEA). In each group, the rate of fatal or disabling non-procedural stroke KaplanMeier estimated was 2.5% at 5years, and 5.3% versus 4.5% for CAS vs CEA for
stroke of any type. The conclusion was that severe complications are similarly rare
with competent CAS and CEA and that the long-term outcomes of both carotid
procedures are comparable in terms of fatal or disabling stroke.
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1.2.1.3 Long-Term Outcome Following CEA andCAS
inSymptomatic Patients
For a comparison of long-term outcome after CEA and CAS in patients with symptomatic carotid stenosis, Brott et al. [6] pooled data from 4 randomised trials
(EVA-3S, SPACE, ICSS and CREST). 4754 patients were followed up for a maximum of 12.4years. The median length of follow-up for each trial ranged from 2.0
to 6.9years. Pooled analysis showed that long-term outcomes after CAS and CEA
were remarkably similar, with an annual rate of ipsilateral stroke per person-year of
0.60% for CEA and 0.64% for CAS.Consequently, patients who experienced no
adverse events in the periprocedural period received qualitatively similar care with
CAS and CEA.Nonetheless, the peri- and post- procedural risks combined favoured
CEA, with treatment differences at 1, 3, 5, 7 and 9years all ranging between 2.8%
(95% CI: 1.1% to 4.4%) and 4.1% (95% CI: 2.0 to 6.3%). The authors concluded
that although long-term outcome (periprocedural and postprocedural risks combined) continued to favour CEA, the similarity in post-procedural outcomes suggests that improvements in the periprocedural safety of CAS may provide similar
outcomes of both procedures in the future.
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1.2.2 Meta-Analyses Open Procedure andCAS
1.2.2.1 Cochrane Reviews: CEA andCAS inSymptomatic
andAsymptomatic Carotid Stenosis
A Cochrane Review [7], based on pooled data from three randomised trials with
6092 patients, came to the following conclusions regarding the balance of benet
vs. risk of CEA versus best possible drug treatment in patients with recent TIA or
non-disabling stroke:
• Surgery increased the 5-year risk of any stroke or surgical death in participants
with stenosis <30% (risk ratio 1.25; 1746 participants, high-quality evidence).
• Surgery reduced the 5-year risk of any stroke or operative death in participants
with stenosis 30% to 49% (risk ratio 0.97; 1429 participants, high-quality
evidence).
• Surgical intervention was of benet in participants with stenosis 50% to 69%
(risk ratio 0.77; 1549 participants, moderate-quality evidence).
• Surgical intervention was of high benet in participants with 70% to 99% steno-
sis without near-occlusion (risk ratio 0.53; 1095 participants, moderate-quality
evidence).
• Surgery reduced the 5-year risk of any stroke or operative death in participants
with a near-occlusion (risk ratio 0.95; 271 participants, moderate-quality
evidence).
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A second Cochrane Review [8] looked at the comparison of CAS and CEA in
asymptomatic and symptomatic patients with carotid stenosis based on 22 trials
(9753 participants). This analysis also included studies comparing CAS with medical therapy alone. According to the results, stenting is associated with a higher risk
of periprocedural stroke or death than CEA in patients with symptomatic carotid
stenosis. The additional risk is mainly due to an increase in minor non-disabling
strokes in patients older than 70years. Beyond the periprocedural period, CAS is as
effective as CEA in preventing recurrent stroke. The combination (safety of the
procedure and long-term effectiveness) still favours endarterectomy. In patients
with asymptomatic carotid stenosis, there may be a small increase in risk of periprocedural stroke or death with stenting compared with endarterectomy. However, the
condence intervals of treatment effects are wide and additional data from randomised trials are needed in patients with asymptomatic stenosis.
1.2.2.2 Redo Stenting or CEA forIn-Stent Stenosis After CAS
Guo etal. [9], in a meta-analysis based on 11 studies with 1057 patients undergoing
revascularisation for in-stent stenosis, found redo stenting (rCAS) in 894 cases and
CEA in 163 patients. Overall, there were no signicant differences between the two
approaches in terms of short- and mid-term stroke rates, death and other perioperative complications. However, in most patients, rCAS is preferred to CEA as the less
invasive procedure for in-stent stenosis, depending on the experience of the
local team.
1.2.2.3 Tandem Carotid Artery Lesions
Tandem lesions, dened as stenoses in the common carotid artery (CCA) or innominate artery combined with stenoses in the ipsilateral internal carotid artery (ICA) or
carotid bifurcation, can be treated with a hybrid approach (CEA of the internal
carotid artery/bifurcation and balloon angioplasty/stenting of the proximal lesion
via the same cervical incision). Qi etal. [10] performed a meta-analysis based on 15
studies and 275 patients. They reported a technical success rate of 99.8% and pooled
perioperative complications rates of death 1.5%, stroke 2.6%, stroke/death 3.3%
and myocardial infarction 3.2%. Overall primary patency rates were 99.2% and
88.2% at 1 and 2years, respectively. Reintervention rates accounted for 6.6% and
pooled overall survival rates were 89.9%, 83.7% and 75.9% at 1, 3 and 5years,
respectively. Operations in which CEA was performed rst had a signicantly
greater risk of perioperative stroke compared with those in which proximal intervention had been performed rst (5.7% vs. 0.0%; p=0.01). The authors considered
the hybrid approach a reasonable option for tandem lesions, with a high technical
success rate. Stenting should be performed before CEA and dual antiplatelet therapy should be given perioperatively.
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1.2.2.4 CEA or CAS forContralateral Carotid Occlusion
Contralateral carotid occlusion is considered a risk factor in CEA.The extent to
which CAS is equivalent to CEA in this situation was investigated by Sun etal. [11]
in a meta-analysis (6 retrospective studies/6953 patients). There were no signicant
differences with regard to perioperative stroke, but CEA was associated with a
reduced risk of death compared with CAS (odds ratio: 0.45; 95% CI: 0.29–0.70;
P<0.001). There was no difference between CEA and CAS in the risk of perioperative myocardial infarction and major adverse cardiovascular events. The reduced
risk of death was mainly found in the subgroups patients <70years, proportion of
men ≥70%, proportion of coronary disease <40%, proportion of hypertension
≥80%, proportion of diabetes mellitus ≥30% and proportion of smokers ≥40%.
The authors considered these factors to be indicative of severe atherosclerosis, with
possible plaque formation, and subsequently plaque detachment in CAS.
1.2.2.5 Synchronous CEA andCoronary Artery Bypass Graft vs.
Staged CAS
In a meta-analysis, Giannopoulos etal. [12] compared synchronous CEA and coronary artery bypass graft (CABG) vs. staged CAS and CABG for patients with concomitant coronary artery disease (CAD) and carotid artery stenosis in terms of
perioperative (30-day) outcomes. They found 5 studies with 16,712 patients.
Coronary bypasses were performed synchronously with CEA (same operating
room, same day) or after CAS, either during the same hospital stay or up to 2months
after. There were no signicant differences in perioperative stroke, TIA and myocardial infarction between the two groups, but patients with simultaneous CEA and
CABG had a signicantly higher risk for perioperative mortality (4% vs. 2%). The
extent to which the different results were due to patient selection could not be claried given the retrospective nature of the study, so that ultimately the question of
whether a staged approach with preference for CAS has advantages must remain
open without further studies.
1.2.2.6 Carotid Interventions Following Thrombolysis
Thrombolytic therapy (TT) is recommended in patients with a suspected acute ischaemic stroke. Approximately 10% to 20% of patients thrombolysed for acute stroke
have an underlying 50% to 90% stenosis of the ipsilateral internal carotid artery and
thus may become candidates for CEA or CAS. Kakkos et al. [13] evaluated the
safety of CAS and CEA after TT.The question is when the procedure is most appropriate, given the increased risk of bleeding. In a meta-analysis of 25 studies
(n = 147,810 patients), 2076 patients underwent CEA and 481 CAS following
TT.Patients with CEA after thrombolysis had a signicantly higher risk of intracerebral haematomas and local haematomas compared to patients with CEA without
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prior thrombolysis. The periprocedural risk was also signicantly higher for CAS.In
the meta-regression analysis, the risk of perioperative death/stroke was 13% if CEA
was performed 3days after thrombolysis and 10.6% when performed after 4days
and up to 6% after 6 to 7days. The message was that it may be safer to defer CEA
for 67 days after TT.
1.2.2.7 Near Infrared Spectroscopy inCarotid Endarterectomy
Near infrared spectroscopy (NIRS) is a cost-effective method to continuously measure cerebral oxygenation non-invasively. NIRS quanties the level of oxygenated
haemoglobin based on its absorption of light in the infrared spectrum. In a systematic review (67 articles), Khan etal. [14] explored the extent to which NIRS is able
to detect intraoperative ischaemic events. They concluded that NIRS has low sensitivity and high specicity to identify intraoperative ischaemia compared with awake
monitoring. The bias risk of the reports was unclear. The NIRS signal dropped consistently after artery clamping in most studies and recovered to baseline values after
de-clamping, with larger drops observed for ischaemic events. Without further studies, the authors did not want to make a nal assessment of the value of the procedure, partly because studies suggest that the external carotid artery contributes to
15% to about 20% of the signals. They only concluded that cerebral monitoring
using near infrared spectroscopy during carotid endarterectomy demonstrates reliable decreases across carotid clamping that may be useful in identifying patients
with ischaemic events.
1.2.2.8 CEA Closure Techniques
A network meta-analysis by Lazarides etal. [15] on carotid artery closure techniques following carotid endarterectomy included 23 randomised trials with 4440
patients, representing seven different techniques: primary carotid closure, n=753;
eversion endarterectomy, n=431; vein patch closure, n=973; PTFE patch, n=948;
Dacron patch, n=828; bovine pericardium patch, n=249; and polyurethane patch,
n=258). Network meta-analysis showed a reduced combined stroke/death rate at
30days for eversion endarterectomy compared with all other methods of arterial
closure, except for PTFE and bovine pericardium. In addition, eversion endarterectomy was associated with the lowest restenosis rate compared with all other methods. Eversion endarterectomy was signicantly superior to Dacron patches with
regard of late restenosis. Rare catastrophic complications of vein patch blow out or
synthetic patch infection were reported in 0.2% of the total (n = 9/4400), so no
comparisons could be made. Eversion endarterectomy and patching with bovine
pericardium or PTFE thus appear to be the best procedures for carotid closure.
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1.2.2.9 Cost-Effectiveness ofCEA andStenting
Sridharan et al. [16] compared the cost-effectiveness of CEA with that of transfemoral carotid artery stenting (TFCAS) and transcarotid arterial revascularisation
(TCAR) for carotid stenosis from a cost-utility standpoint in the United States
healthcare system. Data from CREST (Carotid Revascularisation Endarterectomy
vs. Stenting Trial), the Vascular Quality Initiative Surveillance Project, and local
cost data were included in the analysis. A Markov state-transition model was developed to estimate lifetime costs in $US and effectiveness in QUALYs (qualityadjusted life years) for both asymptomatic and symptomatic patients. In the
base- case scenario, the cost per QUALY gained was $160,642 for TCAR compared
with CEA.TFCAS was less effective than the other strategies and more expensive,
largely due to a greater periprocedural stroke risk. If the risk of stroke with TCAR
was <0.9% (base-case risk, 1.4%), TCAR was economically favorable compared
with CEA at its current procedural cost. In a probabilistic sensitivity analysis, varying all parameters simultaneously over distributions, CEA was favored in 80% of
model iterations at $100,000/QALY, with TCAR favored in 19%. In conclusion, at
current cost and outcomes, TCAR does not meet a traditional cost-effectiveness
threshold to replace CEA as the primary treatment modality for carotid stenosis.
TFCAS is the least cost-effective strategy for carotid revascularisation.
1 Extracranial Carotid Stenosis
1.2.3 Registry Data
1.2.3.1 Prognosis forAsymptomatic Patients Without
Surgical Intervention
Chang etal. [17] reported on a retrospective cohort study of 3737 adults with severe
(70–99%) asymptomatic carotid stenosis diagnosed between 2008 and 2012.
Patients had no previous ipsilateral neurological event or carotid intervention in the
last 6 months. Follow-up extended to 2019. The mean annual stroke rate in this
population was 0.9%; Kaplan-Meier estimated ipsilateral stroke rate at 5years was
4.7% (95% CI 3.9%–5.7%). The non-adjusted all-cause mortality was 51.4%, with
a mean annual mortality rate of 13.6%. The authors concluded that the number of
patients at high risk of stroke in asymptomatic carotid stenosis is likely to be much
smaller than current standards suggest.
1.2.3.2 CAS andCEA vs. Medical Therapy
Keyhani et al. [18] conducted a retrospective cohort study based on data from
219,979 Veterans >65years who received carotid imaging for asymptomatic carotid
stenosis in 2005–2009 and were enrolled in the US Veterans Health Administration
database. They constructed two comparable groups of patients who either received
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medical treatment (n=2509) or were stented (CAS n=551) and followed them for
5years. The observed rate of stroke/death (perioperative complications) at 30days
was 2.2% in the CAS arm. The 5-year risk of fatal and non-fatal stroke was similar
for both groups (CAS 6.9%, medical therapy 7.1%). The message was that no differences in the treatment of asymptomatic carotid stenosis were found between
medical therapy and CAS in this study of older men.
The same group also used the US Veterans Health Administration database to
investigate whether early CEA is superior to initial medical therapy in patients with
asymptomatic carotid stenosis [19]. 2712 patients (98.8% men, mean age 73.6years)
received CEA, and 2509 patients (98.8% men, mean age 73.6years) received initial
medical therapy within 1year after the index carotid imaging. The observed rate of
stroke/death (perioperative complications) within 30days in the CEA cohort was
2.5%. The 5-year risk of fatal and non-fatal stroke was lower in patients randomised
to CEA (5.6%) compared to patients randomised to initial medical treatment (7.8%).
When the risk of non-stroke-related mortality was included in the analysis, there
were no signicant differences in mortality risk between the two cohorts. In this
study, the absolute reduction in the risk of fatal and non-fatal stroke associated with
early CEA was less than half that reported in studies initiated 20years ago. The data
from this study suggest that, given the existing baseline perioperative risk for CEA,
initial medical treatment may be an equally acceptable treatment strategy for asymptomatic carotid stenosis.
1.2.3.3 CEA andCAS Results
Krawisz etal. [20] found 4624 (7.9%) patients with contralateral carotid occlusion
among 58,423 patients who underwent carotid revascularisation. Of those, 68.9%
(n=3185) underwent CAS and 31.1% (1439) underwent CEA. Unadjusted composite outcome rates (in-hospital death/stroke/myocardial infarction) were lower
after CAS than after CEA (2.1% vs. 3.6%). Following adjustment, contralateral
carotid occlusion was associated with a 71% increase in the odds of an adverse
outcome after CEA compared with no increase after CAS.This means that only
with CEA, but not with CAS, contralateral carotid occlusion increased the risk of
intervention.
Perioperative outcome and readmission rates in a total of 378,354 CEA and
57,273 CAS patients were determined over a 6-year period (2010 to 2015) by Cole
et al. [21] using the USA Nationwide Readmissions Database. CEA volume
decreased by an average of 2669 procedures per year (p=0.001) with stable CAS
volume. After matching (CEA n=24,411/CAS n = 24,403), CEA patients had a
higher rate of periprocedural stroke than CAS patients, driven by a higher risk of
stroke in symptomatic patients (8.1% vs. 5.6%; p<0.001), but a lower rate of overall inpatient mortality (0.8% vs. 1.4%; p< 0.001) (Table1.1). CEA patients were
less likely to be readmitted within 30days (7.2% vs. 8.0%; p=0.018). The same
was true for the readmission rate after 90days (12.3% vs. 14.1%; p<0.001). Mean
hospital costs were lower for CEA at $14,433 vs $19,172 with CAS (p<0.001). The
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Table 1.1 Perioperative outcome and readmission rates in CEA and CAS patients. Data from the
Nationwide Readmissions Database. Propensity score matched comparison (according to Cole
etal. [21])
Parameter CAS (n=24,403) CEA (n=24,411) P
Periprocedural
– Stroke 454 (1.9%) 635 (2.6%) < 0.001
– Myocardial infarction 324 (1.3%) 374 (1.5%) 0.062
– Peripheral vascular complication 114 (0.5%) 18 (0.07%) < 0.001
– Respiratory complication 1013 (4.2%) 1187 (4.9%) < 0.001
– Haematoma or bleeding 1014 (4.2%) 1553 (6.4%) < 0.001
On discharge
– Death 342 (1.4%) 192 (0.8%) < 0.001
– Costs (USD) 19,172 14,433 < 0.001
– Re-admission after 30days 1946 (8.0%) 1763 (7.2%) 0.002
– Re-admission after 90days 3439 (14.1%) 3009 (12.3%) <0.001
1 Extracranial Carotid Stenosis
authors emphasised that since the CREST trial was published, which showed nearly
twice the risk of stroke in CAS patients compared with CEA patients, the results of
CAS have improved signicantly. Nevertheless, CEA was associated with lower
procedure cost and readmission rate.
Hammar etal. [22] identied 7653 patients (mean age 72±8years, 67% men)
who underwent primary CEA or CAS for symptomatic carotid stenosis in the
Swedish Swedvasc registry from 2008 to 2017. Peri-operative stroke or death
occurred in 275 patients (64 deaths, 211 strokes), corresponding to 3.6% of the
cohort. The mean follow-up time was reported as 4.21±2.55years. In this cohort,
the incidence rate of any stroke was 1.9% per year after the perioperative period.
1485 (19.6%) patients died during the follow up period, corresponding to a mortality rate of 4.6%/year. Patients treated with CAS had an increased risk of ipsilateral
ischaemic stroke compared with those operated by CEA (adjusted HR 3.20, 95% CI
2.03–5.03). Patients older than 80years had an increased risk of ipsilateral ischaemic stroke compared with patients aged 65–79years (HR 1.94, 95% CI 1.43–2.65).
Stroke of any type was observed in 7.7% of patients. The authors concluded that low
incidence of late ipsilateral ischaemic stroke is obtainable after CEA for symptomatic carotid stenosis. Only age above 80years and CAS compared with CEA were
associated with increased risk of ipsilateral ischaemic stroke.
1.2.4 Transcervical Carotid Artery Revascularization (TCAR)
1.2.4.1 Meta-Analyses ofOutcome After TCAR
A systematic review and meta-analysis of prospective and retrospective studies
reporting the outcomes of patients who had undergone transcervical carotid artery
revascularization (TCAR) for carotid artery was performed by Sagris etal. [23]
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