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

Management of Patients After Transcarotid Artery Revascularization (TCAR)

After TCAR, patients should receive dual antiplatelet therapy with aspirin (81-325 mg daily) plus clopidogrel (75 mg daily) for at least 1 month, followed by long-term single antiplatelet therapy, along with annual follow-up to monitor for cardiovascular risk factors and treatment compliance. 1, 2

Immediate Post-Procedure Management

Hemodynamic Monitoring

• Monitor vital signs closely during the first 24 hours, with particular attention to the first 3 hours when hemodynamic instability most commonly occurs 3
• Aggressively manage blood pressure fluctuations:
  • Treat hypertension promptly to prevent stroke and bleeding complications 1, 2
  • Treat hypotension to maintain adequate cerebral perfusion 2, 3
• Consider phenylephrine infusion to maintain systolic blood pressure between 140-160 mmHg or at patient's baseline 4

Neurological Assessment

• Document findings on clinical neurological examination within 24 hours after TCAR 1
• Perform regular neurological assessments during the first 24 hours to detect early signs of stroke, which typically occurs within the first 4 hours post-procedure 3
• Initiate stroke workup immediately if neurological changes are detected 3

Access Site Care

• Monitor the access site carefully for bleeding, hematoma, or pseudoaneurysm formation 2
• Ensure adequate hemostasis with normal distal blood flow 2

Medication Management

Antithrombotic Therapy

• Dual antiplatelet therapy (DAPT):
  • Aspirin (81-325 mg daily) plus clopidogrel (75 mg daily) for at least 1 month 1, 2
  • For patients intolerant of clopidogrel, ticlopidine (250 mg twice daily) may be substituted 1
• After the initial DAPT period, continue long-term single antiplatelet therapy (either aspirin or clopidogrel) indefinitely 1, 2

Lipid Management

• Initiate intensive lipid-lowering therapy aiming for >50% LDL-C reduction and LDL-C <1.4 mmol/L (55 mg/dL) 1, 2

Blood Pressure Control

• Continue or initiate antihypertensive medications to control blood pressure 1, 2
• Avoid significant fluctuations in blood pressure, which can lead to neurological complications 1, 2

Long-Term Follow-Up

Imaging Surveillance

• Perform initial imaging of extracranial carotid arteries within the first month after TCAR 1, 2
• Schedule subsequent imaging at 6 months and then annually 2
• Use duplex ultrasound as the primary surveillance method 1
• Consider specialized velocity criteria for stented carotids to diagnose significant restenosis:
  • Significant stenosis: Peak-Systolic Velocity ≥3 m/s, End-Diastolic Velocity ≥1.4 m/s 2

Clinical Follow-Up

• Conduct annual follow-up visits to assess:
  • Neurological symptoms
  • Cardiovascular risk factors
  • Treatment adherence
  • Blood pressure control 1, 2
• Monitor for recurrent stenosis, which may require repeat intervention if symptomatic or rapidly progressing 1, 2

Management of Recurrent Stenosis

• For symptomatic patients with recurrent carotid stenosis, repeat revascularization (CEA or CAS) is reasonable using the same criteria as for initial revascularization 1, 2
• For asymptomatic patients with recurrent stenosis:
  • Consider reintervention if stenosis is ≥70% and rapidly progressing or threatens complete occlusion 1, 2
  • Do not perform reoperative CEA or CAS if stenosis is <70% and has remained stable 1, 2

Potential Complications and Management

Hemodynamic Instability

• Occurs in approximately 27.5% of patients, with peak incidence within the first 3 hours post-procedure 3
• Hypotension followed by hypertension are the most common manifestations 3
• Patients with hemodynamic instability may require longer ICU and hospital stays 3

Stroke

• Incidence of stroke after TCAR is approximately 1.0-1.9% within 30 days 5, 6
• Average time to neurologic event is approximately 3.9 hours post-procedure 3
• Immediate neurological assessment and imaging are essential if stroke is suspected 3

Cranial Nerve Injury

• TCAR is associated with a significantly lower rate of cranial nerve injury (0.3%) compared to CEA (3.8%) 5

Common Pitfalls and How to Avoid Them

1. Premature discontinuation of DAPT: Increases risk of stent thrombosis; ensure patients understand the importance of completing the full course of dual antiplatelet therapy 2

2. Inadequate blood pressure control: Can lead to neurological events; maintain strict blood pressure management in the perioperative period 2, 3

3. Insufficient surveillance: May miss restenosis; adhere to recommended imaging schedule based on degree of stenosis 2

4. Unnecessary reintervention: Avoid in asymptomatic patients with stable, moderate stenosis (<70%) 1, 2

5. Overlooking contralateral carotid disease: Consider more frequent monitoring if significant stenosis exists in the contralateral carotid artery 2

By following these evidence-based recommendations, clinicians can optimize outcomes for patients after TCAR, minimizing the risk of stroke, restenosis, and other complications while ensuring appropriate long-term management.