For patients with high risk or anatomically challenging lesions, transcarotid artery revascularization (TCAR) is recommended over transfemoral stenting (TFCAS) and carotid endarterectomy (CEA). “TCAR is an ideal tool for many patients,” says vascular surgeon Cynthia K. Shortell, MD, who introduced TCAR at Duke. “Duke was the first in the area to perform TCAR, and we have the most experience.”

“This is a newer technology, but we were a very early adopter,” agrees Duke Health vascular surgeon Zachary F. Williams, MD. “We’re nationally recognized on the leading edge of research. With our facilities and our stroke team, Duke is a great place for stroke prevention.”

Williams’s research has brought TCAR to more patients. “We’re pushing the envelope on who can get TCAR,” says Williams. His research includes a retrospective study of a case series with patients receiving TCAR simultaneously with coronary artery bypass graft (CABG). Rather than the standard incision above the clavicle to insert the stent, surgeons approached through the chest incision for CABG. No patients in the series experienced adverse effects.

Williams also contributed to research to offer TCAR to patients with unfavorable anatomy for either CEA or TCAR. “One of the limitations for TCAR is that you need 5 cm of healthy common carotid artery to access it. For people who don’t have that, we’ve sewn on a prosthetic conduit and performed TCAR through the conduit,” he explains.

Additionally, the ROADSTER-3 trial enrolled 344 patients without anatomical or physiological risk at multiple centers. In the one-year follow-up data, presented at the Vascular Interventional Advances (VIVA) conference in November 2025, the incidence of major adverse events remained low at only 1.3% of the per-protocol population (n=305). Williams served as the primary investigator for the Duke site of the study. The study data has helped gain FDA approval for TCAR for standard risk patients.

For patients with carotid stenosis, early referral is key. “Any patient with carotid stenosis of 50% or greater should be referred to be managed by a vascular specialist,” says Shortell.

Patients may not require surgical intervention right away, but evaluation can help determine the most appropriate therapy and approach. “Vascular providers have the deepest knowledge of treating the condition,” Shortell continues.

“Anyone with a symptomatic lesion would be an urgent referral,” Williams adds. “A carotid bruit or known stenosis requires a screening ultrasound, which we’re happy to coordinate with referring providers on.”