What are the next steps for a patient who fails to thrive after Transcarotid Artery Revascularization (TCAR)?

Management of Failure to Thrive After TCAR

For patients who fail to thrive after Transcarotid Artery Revascularization (TCAR), immediate evaluation by a vascular specialist with structured neurological assessment and imaging is recommended to identify and address the underlying cause. 1

Initial Assessment (Within 24 Hours)

• Formal neurological examination: Document findings and compare to pre-procedure baseline 2
• Vital sign monitoring: Focus on blood pressure management to avoid fluctuations 2
• Access site evaluation: Check for bleeding, hematoma formation, or infection (occurs in ~5% of cases) 2
• Laboratory studies: Complete blood count, renal function, cardiac enzymes

Diagnostic Imaging

• Duplex ultrasound: First-line imaging to evaluate stent patency and carotid flow 1
• CTA or MRA: If duplex is inconclusive or neurological symptoms are present 1
• Brain imaging: CT or MRI if neurological symptoms are present to rule out stroke

Common Causes of Failure to Thrive After TCAR

1. Stent-related complications:

   • Stent thrombosis
   • In-stent restenosis (use specialized velocity criteria: significant stenosis ≥3 m/s peak-systolic velocity) 2
   • Stent malposition or migration

2. Neurological complications:

   • Stroke (occurs in 1.0-1.9% of TCAR patients within 30 days) 3, 4
   • Hyperperfusion syndrome

3. Hemodynamic issues:

   • Persistent hypotension (consider oral ephedrine 25-50 mg, 3-4 times daily) 2
   • Hypertension requiring aggressive management

4. Access site complications:

   • Neck hematoma (occurs in 2-8% of cases) 5, 6
   • Wound infection
   • Carotid artery injury

5. Cardiac complications:

   • Myocardial infarction (occurs in 0.9% of TCAR patients) 4
   • Heart failure exacerbation

Management Algorithm

For Stent-Related Issues:

• If stent thrombosis: Urgent revascularization is recommended within hours 1
• If in-stent restenosis:
  • Symptomatic patients: Repeat revascularization (CAS or CEA) using same criteria as initial procedure 2
  • Asymptomatic patients with >70% stenosis that has progressed rapidly: Consider repeat intervention 2
  • Asymptomatic patients with <70% stable stenosis: Medical management only 2

For Neurological Complications:

• If stroke confirmed: Initiate stroke protocol and consult neurology
• If hyperperfusion syndrome: Strict blood pressure control, anticonvulsants if seizures present

For Hemodynamic Issues:

• Persistent hypotension: Consider oral ephedrine (25-50 mg, 3-4 times daily) 2
• Hypertension: Administer antihypertensive medication to control blood pressure 1

For Access Site Complications:

• Neck hematoma requiring evacuation: Surgical intervention 6
• Minor hematoma: Observation and compression
• Infection: Appropriate antibiotics

For Cardiac Complications:

• Myocardial infarction: Cardiology consultation and standard cardiac care
• Heart failure: Optimize volume status and cardiac medications

Medication Management

• Maintain dual antiplatelet therapy: Aspirin (81-325 mg daily) plus clopidogrel (75 mg daily) for minimum 30 days after TCAR 1, 2
• Continue statin therapy: Aim for >50% LDL-C reduction and LDL-C <1.4 mmol/L (55 mg/dL) 2
• Optimize blood pressure control: Administer antihypertensive medication as needed 1

Follow-up Protocol

• Initial post-procedure imaging: Within 30 days 2
• Subsequent imaging: At 6 months and annually thereafter 2
• Frequency adjustment based on stenosis:
  • <50% stenosis: Annual or every 3-6 years if stable 2
  • 50-69% stenosis: Every 6-12 months 2
  • ≥70% stenosis: Every 6 months 2

Important Pitfalls to Avoid

• Premature discontinuation of dual antiplatelet therapy: Increases risk of stent thrombosis 2
• Inadequate blood pressure control: Increases risk of neurological events 2
• Unnecessary intervention for asymptomatic patients with stable, moderate stenosis (<70%) 2
• Overutilization of imaging in patients with minimal stenosis and no progression 2
• Delayed recognition of neck hematoma: Can lead to airway compromise if not addressed promptly

By following this structured approach to evaluating and managing patients who fail to thrive after TCAR, clinicians can effectively identify and address the underlying causes, optimize outcomes, and reduce the risk of complications.