Is transcarotid artery revascularization (TCAR) recommended for a patient with complete occlusion of the right internal carotid artery (ICA)?

TCAR is Not Recommended for Complete Occlusion of the Right Internal Carotid Artery

TCAR (transcarotid artery revascularization) is not recommended for patients with chronic total occlusion of the internal carotid artery. 1

Rationale for Not Performing TCAR in ICA Occlusion

Guidelines-Based Recommendations

The 2011 AHA/ASA guidelines explicitly state as a Class III recommendation (No Benefit):

• "Carotid revascularization is not recommended for patients with chronic total occlusion of the targeted carotid artery." (Level of Evidence: C) 1

This recommendation applies to all forms of carotid revascularization, including:

• Carotid endarterectomy (CEA)
• Carotid artery stenting (CAS)
• Transcarotid artery revascularization (TCAR)

Pathophysiology and Outcomes

The management approach differs significantly between carotid stenosis and complete occlusion:

• In complete occlusion:
  • The vessel is already fully blocked
  • Revascularization attempts carry significant risks
  • Success rates for recanalization of chronic occlusions are poor
  • The risk-benefit ratio does not favor intervention 2

Alternative Management Approaches

For patients with complete occlusion of the right ICA, management should focus on:

1. Medical therapy:

   • Antiplatelet therapy (aspirin 75-325 mg daily or clopidogrel 75 mg daily) 1
   • Aggressive risk factor modification (lipid management, blood pressure control)
   • Smoking cessation if applicable

2. Evaluation of collateral circulation:

   • CT perfusion can be used to determine the hemodynamic effect of complete extracranial ICA occlusion 1
   • However, selection of patients with carotid occlusion for revascularization based on hemodynamic compromise has not been shown to improve outcomes 1

3. Monitoring for contralateral disease:

   • Regular surveillance of the contralateral carotid artery
   • Management of any stenosis in the contralateral carotid to prevent further compromise

Special Considerations

Acute vs. Chronic Occlusion

It's important to distinguish between acute and chronic occlusion:

• Acute symptomatic occlusion (within hours):

  • May be considered for emergent endovascular therapy in specialized centers
  • Better recanalization rates with mechanical approaches compared to pharmacological thrombolysis alone 3
  • However, outcomes remain poor with only 28% achieving favorable outcomes at 3 months 3

• Chronic occlusion:

  • Revascularization is not recommended 1
  • Medical management is the mainstay of treatment

Risk of Future Strokes

• Symptomatic ICA occlusion increases the risk of future strokes compared to asymptomatic occlusion 2, 4
• Approximately 25-30% of patients with ICA occlusion may experience further ischemic attacks 5
• The cause of ischemia is generally embolization via collateral circulation through the external carotid artery 5

Conclusion

For a patient with complete occlusion of the right internal carotid artery, TCAR is not recommended based on current guidelines. Management should focus on optimal medical therapy, risk factor modification, and surveillance of the contralateral carotid artery to prevent further cerebrovascular events.