How do you decide between TCAR vs. carotid stenting for patients unstable for CEA?

There would be several factors, but the most important being the experience and outcomes from the local operators. If they have great outcomes with tcar and poor with stent then it’s the primary driving force. Other factors that could favor tcar would be a hostile arch anatomy and a thinner neck; favoring stent might be post radiation stenosis. A key factor ultimately is also involving the patient.

Agree, you need a good TCAR track record (which is kind of an oxymoron as all the TCAR cases were proctored for so long post-market that their complication rates are so low so almost any center with experience doing TCAR should have a decent track record).

Anatomy and patient preference are the key components. If you don't have at least 5 cm from the clavicle to the carotid bifurcation then you can't do TCAR.

Another issue with the vascular surgeons I work with has been the theoretical "flow rev...