What is the surgical technique for Transcarotid Artery Revascularization (TCAR)?

From the Guidelines

Transcarotid artery revascularization (TCAR) is a minimally invasive surgical technique that involves accessing the common carotid artery through a small incision, clamping the carotid artery, and inserting a sheath to create a temporary reversal of blood flow away from the brain, allowing for the deployment of a stent across the stenotic lesion while preventing embolic debris from traveling to the brain. This technique is supported by recent evidence, including large registry-based analyses that report a high technical success rate and low complication rates 1. The procedure typically involves a combination of surgical exposure and endovascular techniques, and can be performed under local, regional, or general anesthesia.

Key steps in the TCAR procedure include:

• Accessing the common carotid artery through a small incision (2-3 cm) at the base of the neck
• Clamping the carotid artery proximally and inserting a sheath toward the heart to create a temporary reversal of blood flow
• Deploying a stent across the stenotic lesion in the carotid artery using standard endovascular techniques
• Using a filter system (such as the ENROUTE Transcarotid Neuroprotection System) to capture any plaque debris before returning the filtered blood to the femoral vein
• Removing the system and closing the arteriotomy after stent placement

The benefits of TCAR include:

• Minimally invasive approach with reduced risk of stroke during the procedure
• Controlled access to the carotid artery
• Cerebral protection through flow reversal
• Suitability for high-risk patients with anatomically challenging lesions or those who are poor candidates for traditional carotid endarterectomy
• Low complication rates, with a reported 30-day stroke/death rate of less than 3% and a 1-year rate of stroke or death of 6.4% 1

From the Research

Surgical Technique for Transcarotid Artery Revascularization (TCAR)

The surgical technique for TCAR involves a less invasive approach compared to traditional carotid endarterectomy (CEA) or transfemoral carotid artery stenting (TFCAS) 2, 3, 4, 5. Key aspects of the TCAR procedure include:

• Use of flow reversal to minimize the risk of stroke during the procedure 3
• A smaller incision compared to CEA, resulting in less tissue trauma and potentially fewer complications 3, 5
• Placement of a stent in the carotid artery to maintain patency and prevent restenosis 2, 4

Comparison with Other Revascularization Techniques

Studies have compared the outcomes of TCAR with CEA and TFCAS, with results indicating that TCAR may be a viable alternative for high-risk patients 2, 3, 4, 5. Key findings include:

• Similar rates of in-hospital stroke and death for TCAR and CEA 3, 5
• Lower rates of cranial nerve injury and shorter procedure times for TCAR compared to CEA 3, 5
• Potential benefits of TCAR over TFCAS in terms of reduced stroke risk and improved outcomes in high-risk patients 2, 4

Patient Selection and Eligibility

Patient selection and eligibility for TCAR are critical factors in determining the success of the procedure 2. Key considerations include:

• Anatomic criteria, such as carotid artery diameter and distance from the clavicle to the carotid bifurcation 2
• Medical comorbidities, such as coronary artery disease, chronic obstructive pulmonary disease, and chronic kidney disease 3, 5
• Symptomatic status and degree of carotid stenosis 4, 5