What is the recommended management plan for patients after Transcarotid Artery Revascularization (TCAR)?

Post-operative TCAR Management

After Transcarotid Artery Revascularization (TCAR), patients should receive dual antiplatelet therapy with aspirin (81-325 mg daily) plus clopidogrel (75 mg daily) for a minimum of 30 days, followed by long-term single antiplatelet therapy, along with structured surveillance imaging and risk factor management. 1

Immediate Post-operative Care (0-24 hours)

• Neurological monitoring: Document formal neurological assessment within 24 hours after TCAR 1
• Blood pressure management: Administer antihypertensive medications as needed to control blood pressure and avoid fluctuations 1
  • Treat both hypertension and hypotension promptly to prevent complications
  • Consider oral ephedrine (25-50 mg, 3-4 times daily) for persistent hypotension
• Access site care: Monitor for bleeding, hematoma formation, or infection (complications in ~5% of cases) 1
• Discharge planning: Stable and neurologically intact patients may be discharged on the first post-procedural day 1

Antiplatelet and Medication Management

• Dual antiplatelet therapy (DAPT):
  • Aspirin (81-325 mg daily) plus clopidogrel (75 mg daily) for minimum 30 days 1
  • For patients intolerant of clopidogrel, ticlopidine (250 mg twice daily) may be substituted 1
• Long-term antiplatelet therapy:
  • After initial DAPT period, continue single antiplatelet therapy indefinitely (aspirin or clopidogrel) 1
• Statin therapy:
  • Intensive lipid-lowering therapy aiming at >50% LDL-C reduction and LDL-C <1.4 mmol/L (55 mg/dL) 1, 2
• Other medications:
  • Continue or initiate medications for hypertension, diabetes, and other cardiovascular risk factors 1
  • Smoking cessation should be strongly encouraged 1

Surveillance Protocol

• First month: Initial imaging of extracranial carotid arteries within 30 days post-procedure 1, 2
• Follow-up imaging schedule:
  • 6 months after procedure 1, 2
  • Annually thereafter 1, 2
  • More frequent monitoring (every 6 months) if rapid progression is detected 2
• Specialized velocity criteria for stented carotids:
  • Significant restenosis: Peak-systolic velocity ≥3 m/s and end-diastolic velocity ≥1.4 m/s 2
  • Non-significant restenosis: Peak-systolic velocity <3 m/s and end-diastolic velocity <1.4 m/s 2
• Clinical follow-up:
  • Annual assessment of neurological symptoms, cardiovascular risk factors, and medication adherence 1, 2

Management of Restenosis

• For symptomatic patients with recurrent stenosis:
  • Repeat revascularization (CAS or CEA) is reasonable using the same criteria as for initial revascularization 1
• For asymptomatic patients with recurrent stenosis:
  • Consider repeat intervention if stenosis >70% and has progressed rapidly or threatens complete occlusion 1
  • Reoperative CEA or CAS should NOT be performed in asymptomatic patients with <70% carotid stenosis that has remained stable 1

Advantages of TCAR vs. Other Approaches

• TCAR has demonstrated comparable 30-day stroke/death rates to CEA (1-3% for TCAR vs. 1-2% for CEA) 3, 4, 5
• TCAR is associated with significantly lower rates of cranial nerve injury compared to CEA (0.3-1% vs. 3-5%) 3, 5, 6
• TCAR may have higher late restenosis rates compared to CEA at 2-year follow-up (3% vs. 0.5-0.9%) 5

When to Discontinue Surveillance

• Surveillance can be discontinued when:
  • Stability has been established over an extended period 1, 2
  • Patient is no longer a candidate for intervention 1, 2
  • Patient has limited life expectancy (<5 years) 2

Pitfalls to Avoid

• Inadequate antiplatelet therapy: Premature discontinuation of DAPT increases risk of stent thrombosis 1
• Suboptimal blood pressure control: Both hypertension and hypotension increase risk of neurological events 1
• Insufficient surveillance: Late restenosis can occur years after the procedure 2
• Unnecessary intervention: Avoid reoperative procedures for asymptomatic patients with stable, moderate stenosis (<70%) 1, 2

By following this structured post-operative management plan, patients who undergo TCAR can achieve optimal outcomes with minimal complications.