Symptomatic Carotid Artery Disease Differentially Affects Outcomes After Carotid Endarterectomy, Transcarotid Revascularization, and Transfemoral Carotid Artery Stenting.

OBJECTIVE: Symptomatic carotid artery stenosis is associated with a greater risk of stroke than asymptomatic disease. However, the influence of symptom status on outcomes across contemporary carotid revascularization strategies remains incompletely understood. We compared perioperative and long-term outcomes following carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TF-CAS) according to symptom status. METHODS: A retrospective review of a prospectively maintained institutional carotid revascularization database was performed, including patients undergoing CEA, TCAR, or TF-CAS between March 2003-August 2025. Patients were stratified by symptomatic vs. asymptomatic presentation. The primary outcome was 30-day stroke/death. Secondary outcomes included myocardial infarction, cranial nerve injury, thrombosis, reintervention, and long-term stroke-free survival. Multivariable logistic regression was used to evaluate procedure-specific outcomes and the independent association between symptom status and 30-day stroke/death. RESULTS: A total of 2,657 patients had symptom status available, including 1,830 asymptomatic (68.9%) and 827 symptomatic (31.1%). Among asymptomatic patients, 30-day stroke/death did not differ significantly among CEA, TCAR, and TF-CAS (1.8%, 1.6%, and 2.3%, respectively; P=.843). In symptomatic patients, stroke/death differed significantly across procedures (4.8%, 4.2%, and 14.5%, respectively; P=.005). After adjustment, no differences in stroke/death were observed among procedures in the asymptomatic cohort. In symptomatic patients, TF-CAS was associated with higher odds of 30-day stroke/death compared with both CEA (OR, 3.38; 95% confidence interval [CI], 1.27-9.02; P=.015) and TCAR (OR, 4.32; 95% CI, 1.56-11.95; P=.005). Compared with CEA, TCAR demonstrated comparable adjusted odds of stroke/death (OR, 0.78; 95% CI, 0.38-1.62; P=.510) and stroke (OR, 0.69; 95% CI, 0.31-1.53; P=.361) in symptomatic cohort. Symptomatic presentation independently increased the risk of 30-day stroke/death following CEA (OR, 3.68; 95% CI, 1.77-7.64; P<.001) and TF-CAS (OR, 9.12; 95% CI, 1.46-56.97; P=.018). A similar association was observed following TCAR. However, statistical significance was not reached (OR, 2.49; 95% CI, 0.89-6.94; P=.082). Long-term stroke-free survival was significantly lower among symptomatic patients across all revascularization modalities (all log-rank P<.01). CONCLUSIONS: Among symptomatic patients, TF-CAS was associated with higher 30-day stroke/death rates compared with both CEA and TCAR. In contrast, CEA and TCAR demonstrated comparable perioperative outcomes across symptomatic and asymptomatic cohorts. These findings support symptom-stratified procedure selection and reinforce CEA and TCAR as preferred revascularization strategies for symptomatic carotid artery disease.