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 patients with significant carotid stenosis who also have high-risk features, such as:
- High lesions (extending cranially to the second cervical vertebra)
- Cervical spine immobility
- Post-CEA restenosis
- Prior neck irradiation
- Hostile neck These patients may have a lower risk of stroke or death with TCAR compared to traditional carotid endarterectomy (CEA) or transfemoral carotid artery stenting (tfCAS) 1. TCAR has specific anatomical requirements, including a disease-free common carotid artery and a ≥5 cm clavicle-carotid bifurcation distance, which need to be taken into consideration when selecting patients for this procedure. The use of flow reversal technology in TCAR reduces the risk of procedural embolic stroke by directing potential emboli away from the brain 1.
The decision to perform TCAR should be made after multidisciplinary evaluation considering the patient's overall vascular anatomy, comorbidities, and stroke risk factors. Patients undergoing TCAR typically require dual antiplatelet therapy for at least 30 days after the procedure, followed by aspirin indefinitely 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 tfCAS, 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)
- TCAR is indicated for patients with symptomatic carotid stenosis, particularly those with significant stenosis 2
- It is also considered for patients with asymptomatic carotid stenosis of ≥70%, especially those with high-risk criteria for carotid endarterectomy (CEA) or transfemoral carotid artery stenting (TFCAS) 3
- TCAR may be a relevant alternative to CEA, especially in high-risk patients, due to its promising results and reduced perioperative complications 2, 4, 5
- The technique has also been explored for intracranial carotid artery stenosis, with potential benefits of reduced stroke risk compared to traditional carotid artery stenting 6
Patient Selection
- Patients with symptomatic carotid stenosis ≥50% may be considered for TCAR 4, 5
- Asymptomatic patients with carotid stenosis ≥70% may also be considered, particularly those with high-risk criteria for CEA or TFCAS 3, 4
- Patients with intracranial carotid artery stenosis may be considered for TCAR, especially if they have limited surgical treatment options 6
Considerations
- The choice of TCAR should be based on the presence or absence of high-risk criteria for each specified intervention, including CEA, TCAR, and TFCAS 3
- Institutions and operators performing TCAR must exhibit expertise sufficient to meet established guidelines for treatment of patients with carotid stenosis 3