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 anatomy These patients may benefit from TCAR due to its potential to reduce the risk of stroke or death compared to traditional carotid endarterectomy (CEA) or transfemoral CAS (tfCAS) 1. TCAR has specific anatomical requirements, including a disease-free common carotid artery and a ≥5 cm clavicle-carotid bifurcation distance, which must be taken into consideration when selecting patients for this procedure 1. The use of dynamic flow reversal in TCAR has been suggested to serve as the primary mechanism of procedural stroke reduction, making it a promising technique for high-risk patients 1. However, further randomized controlled trials are needed to compare TCAR with CEA, tfCAS, and 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 (>50%) 2.
- TCAR may be considered for patients with asymptomatic carotid stenosis (>70%) who have a life expectancy of 3 to 5 years and a low risk of perioperative stroke and death (<3%) 3.
- The choice of TCAR versus other treatment options, such as carotid endarterectomy (CEA) or transfemoral carotid artery stenting (TFCAS), should be based on individual patient risk factors and the presence of high-risk criteria for each procedure 3, 4.
- TCAR has shown promising results in high-risk patients, with outcomes similar to those of CEA, but additional studies are needed to evaluate long-term outcomes 5.
Patient Selection
- Patients with symptomatic carotid stenosis who are at high risk for CEA may be suitable candidates for TCAR 2, 5.
- Asymptomatic patients with carotid stenosis (>70%) who have a low risk of perioperative stroke and death (<3%) may also be considered for TCAR 3.
- The timing of TCAR in symptomatic patients does not appear to affect outcomes, with similar results seen in patients undergoing procedure within 2-5 days or 6-180 days after onset of symptoms 6.