TCAR
- Daniel Torrent
- May 27, 2024
- 2 min read
One option for patients with carotid disease who need surgery is transcarotid artery revascularization (TCAR). This is a minimally invasive approach that allows the surgeon to place a stent to open up the narrowed artery while minimizing the risk of stroke. TCAR is used for patients who have carotid artery stenosis that is causing an increased risk of stroke.
It is a good option in patients where carotid endarterectomy, the standard surgical option, is higher risk because of anatomy considerations or other health factors.
With TCAR, a small incision is made at the base of the neck allowing the surgeon to directly access the artery with a sheath. A second sheath is placed in a large vein the groin using ultrasound with no incision required beyond a small puncture. These two sheaths are connected by a special circuit that allows blood flow in the carotid artery to be reversed during the procedure. This functions to prevent strokes. Typically, if any pieces of plaque were to break free they would travel towards the brain and result in a stroke.
With this flow reversal system in place those pieces would flow backwards and into the tubing in the circuit. The tubing has a filter that captures these pieces with the rest of the blood being returned to the blood in the groin. Once this is in place a balloon is used to open up the narrowed artery and then a stent is placed to maintain the new opening.
With all carotid interventions a big concern is the risk of causing a stroke. With TCAR that risk is very low and appears to be similar to the risk with the standard surgery approach. This is in contrast to the other method of stenting coming from the groin which has a higher stroke risk. The other frequent concern with procedures on the carotid artery are related to nerve injuries. The neck has a number of large and important nerves which can be at risk during surgery. With TCAR that risk is very low because the amount of surgery that needs to be done to free up the small section of the blood vessel needed is very limited. This is compared to the standard surgery where the risk of nerve injury is higher.
Medications are an important part of TCAR. Prior to the procedure the patient should be on two antiplatelet drugs (typically aspirin and clopidogrel) and usually a statin (a type of cholesterol medication). This is to prevent clots from forming on the stent. The medications are typically started at least several days before the procedures and remain for weeks afterwards. The antiplatelet medications can often be tapered to just one medication after a period of time though in some situations both medications are left indefinitely.
After the procedure the patient is monitored overnight. As long as everything goes well they are usually discharged the following day with plans for follow up in the office to make sure the incision is healing well as well as to plan for ultrasounds to evaluate the stent and keep track of it over time.
