Post-Operative Orders for TransCarotid Artery Revascularization (TCAR)
Patients undergoing TCAR should receive dual antiplatelet therapy (aspirin 81-325 mg plus clopidogrel 75 mg daily) for at least 30 days post-procedure, with close hemodynamic and neurological monitoring in a step-down unit rather than ICU for most patients. 1
Immediate Post-Operative Monitoring (First 24 Hours)
Neurological Assessment
- Formal neurological examination must be documented within 24 hours after the procedure 1
- Continuous neurological monitoring should occur in the immediate post-operative period, with particular attention to new focal deficits, altered consciousness, or signs of stroke 1
- Patients who are neurologically stable and intact may be discharged on the first post-procedural day 1
Hemodynamic Management
- Blood pressure fluctuations (both hypertension and hypotension) are common and must be treated promptly 1
- Post-operative hypertension increases risk of stroke, TIAs, wound bleeding, and intracranial hemorrhage and requires aggressive pharmacological control 1
- For persistent hypotension in neurologically intact patients, consider oral ephedrine 25-50 mg three to four times daily 1
- Intravenous antihypertensives or vasopressor support may be needed in approximately 7-10% of patients 2
- Most patients (92%) do not require ICU-level care and can be safely managed in a step-down unit or post-anesthesia care unit 2
Access Site Care
- Monitor the cervical access site for hematoma formation, bleeding, or signs of infection 1
- Neck hematomas, though rare, require immediate attention as they can compromise the airway 2
Antiplatelet Therapy
Mandatory Dual Antiplatelet Therapy (DAPT)
- Aspirin 81-325 mg daily PLUS clopidogrel 75 mg daily for a minimum of 30 days post-procedure (Class I recommendation) 1
- For patients intolerant of clopidogrel, ticlopidine 250 mg twice daily may be substituted 1
- Avoid ticagrelor in DAPT regimens following TCAR due to elevated bleeding risk compared to clopidogrel 1
Long-Term Antiplatelet Therapy (After 30 Days)
- Continue single antiplatelet therapy indefinitely with either aspirin 81-325 mg daily OR clopidogrel 75 mg daily 1
Blood Pressure Management
- Antihypertensive medications must be administered to control blood pressure both immediately post-procedure and long-term (Class I recommendation) 1
- Resume or initiate pre-existing antihypertensive regimens as soon as hemodynamically stable 1
- Target blood pressure control to prevent both hypertensive complications and hypotension-related cerebral hypoperfusion 1
Additional Medical Management
Lipid Management
- Initiate or continue intensive lipid-lowering therapy targeting >50% LDL-C reduction and LDL-C <1.4 mmol/L (55 mg/dL) 1
- Statin therapy should be administered to all patients regardless of baseline lipid levels 3
Cardiovascular Risk Factor Modification
- Smoking cessation counseling and support 1
- Diabetes management optimization 1
- Resume or initiate medications for hyperlipidemia control 1
Surveillance Imaging
Initial Follow-Up
- Duplex ultrasound surveillance within the first month post-procedure to establish baseline and assess patency 1, 3
- Follow-up imaging at 6 months to exclude development of new or contralateral lesions 1, 3
- Annual surveillance thereafter to monitor for restenosis 1, 3
Extended Surveillance
- Once stability is established over an extended period, surveillance intervals may be lengthened 1, 3
- Surveillance may be terminated when the patient is no longer a candidate for intervention 1, 3
Hospital Stay and Discharge Planning
Length of Stay
- Mean hospital stay is approximately 1.4 days for patients undergoing regional anesthesia 2
- Patients requiring general anesthesia may have longer stays (mean 4.2 days) 2
- Neurologically stable patients without hemodynamic instability can be discharged on post-operative day 1 1
Discharge Criteria
- Neurologically intact with stable examination 1
- Hemodynamically stable without need for intravenous vasoactive medications 2
- No access site complications (hematoma, bleeding) 1
- Tolerating oral medications including DAPT 1
Common Pitfalls and Complications
Hemodynamic Instability
- Approximately 7-10% of patients require intravenous blood pressure medications post-operatively 2
- Persistent hypotension may require extended in-hospital observation beyond 24 hours 1
- Both hypertension and hypotension must be aggressively managed to prevent neurological complications 1
Neurological Events
- Perioperative stroke rate is approximately 1.2-2.4%, with most being minor and fully recoverable 2, 4
- Any new neurological deficit requires immediate evaluation and imaging 1
- Recrudescence of prior stroke symptoms can occur and should not automatically be attributed to new ischemia 2
Mortality Risk
- Overall 30-day mortality is approximately 2.6-4.9%, with higher rates in symptomatic patients 4, 5
- Most deaths occur after discharge and are from non-neurological causes (cardiac, respiratory) 4
- In-hospital mortality from the index procedure is approximately 1.2% 4
Access Site Complications
- Monitor for neck hematoma, which can compromise airway 2
- Cervical access site complications are generally less frequent than femoral access complications seen with transfemoral carotid stenting 1
Special Considerations
Symptomatic Patients
- Symptomatic patients (those with neurological events within 180 days) have similar perioperative stroke rates but may have higher mortality risk 4
- These patients may benefit from ICU monitoring if they had significant pre-operative neurological deficits 2