From the Guidelines
Transcarotid Artery Revascularization (TCAR) is indicated for patients with carotid artery stenosis who are at high surgical risk and have concomitant severe aortic or femoral artery pathology, as well as those with specific anatomical considerations such as high lesions, cervical spine immobility, post-CEA restenosis, prior neck irradiation, and hostile neck. The primary indications for TCAR include:
- Significant carotid stenosis (typically ≥70% in symptomatic patients or ≥80% in asymptomatic patients) combined with anatomical or physiological high-risk features, such as previous neck radiation, previous neck surgery, contralateral carotid occlusion, high cervical lesions, restenosis after previous carotid intervention, severe cardiopulmonary disease, or age greater than 80 years 1.
- Patients with tandem lesions involving both the carotid and intracranial vessels may also be considered for TCAR. The procedure uses flow reversal technology to reduce the risk of procedural embolic stroke by temporarily reversing blood flow away from the brain during stent placement, which has been suggested to serve as the primary mechanism of procedural stroke reduction in TCAR 1. Before proceeding with TCAR, patients should undergo comprehensive vascular imaging (CTA, MRA, or conventional angiography) to confirm stenosis severity and assess anatomical suitability, and a thorough evaluation of comorbidities to determine procedural risk. It is essential to consider the specific anatomical requirements for TCAR, including a disease-free common carotid artery and a ≥5 cm clavicle-carotid bifurcation distance, as well as minimal to no common carotid artery puncture-site atherosclerosis 1. While TCAR has shown promise, particularly in high-risk patients, randomized or large multi-centre prospective trials with independent neurological and radiographic adjudication are needed to compare TCAR with transfemoral CAS (tfCAS), carotid endarterectomy (CEA), and/or best medical therapy strategies in both high-risk and average-risk patients 1.
From the Research
Indications for Transcarotid Artery Revascularization (TCAR)
The indications for TCAR include:
- Severe asymptomatic or symptomatic carotid stenosis with high-risk lesions defined as lesions 2 cm or longer and/or >50% of the lesion containing soft plaque or bleeding carotid pseudoaneurysm 2
- Asymptomatic >70% carotid stenosis 2
- Transient ischemic attack-like symptoms and >70% stenosis 2
- Bleeding carotid pseudoaneurysm 2
- Significant symptomatic carotid stenosis, particularly in high-risk patients 3, 4, 5
Patient Selection
Patient selection for TCAR is based on anatomic criteria, including:
- Internal carotid artery (ICA) diameter of 4-9 mm 6
- Common carotid artery (CCA) diameter of ≥6 mm 6
- Clavicle to carotid bifurcation distance of ≥5 cm 6
- Absence of significant CCA puncture site plaque 6
- Bifurcation anatomy favorable for stenting 6
High-Risk Patients
TCAR may be a viable option for high-risk patients, including those with: