From the Guidelines
Transcarotid artery revascularization (TCAR) does not specifically require ions as part of the procedure, but rather involves careful management of anticoagulation and antiplatelet therapy. For TCAR, patients typically receive antiplatelet therapy with aspirin (81-325 mg daily) and clopidogrel (75 mg daily) starting at least 5 days before the procedure or a loading dose of clopidogrel (300-600 mg) if urgent, as recommended by guidelines for the prevention of stroke in patients with stroke or transient ischemic attack 1. During the procedure, heparin is administered to achieve an activated clotting time (ACT) of 250-300 seconds. After TCAR, dual antiplatelet therapy with aspirin and clopidogrel is continued for at least 30 days, followed by lifelong aspirin therapy.
Key Considerations
- Electrolyte management, particularly maintaining normal levels of sodium, potassium, calcium, and magnesium, is important for cardiovascular stability during the procedure, but specific ion administration is not a standard part of TCAR protocols.
- The procedure itself involves creating temporary flow reversal in the carotid artery to prevent embolic stroke while placing a stent, rather than requiring specific ion therapies.
- Optimal medical therapy, which should include antiplatelet therapy, statin therapy, and risk factor modification, is recommended for all patients with carotid artery stenosis and a TIA or stroke as outlined in guidelines 1.
Procedure Details
- Patients at average or low surgical risk who experience nondisabling ischemic stroke or transient cerebral ischemic symptoms, including hemispheric events or amaurosis fugax, within 6 months (symptomatic patients) should undergo CEA if the diameter of the lumen of the ipsilateral internal carotid artery is reduced more than 70% as documented by noninvasive imaging or more than 50% as documented by catheter angiography, with an anticipated rate of perioperative stroke or mortality less than 6% 1.
- CAS is indicated as an alternative to CEA for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by more than 70% as documented by noninvasive imaging or more than 50% as documented by catheter angiography, with an anticipated rate of periprocedural stroke or mortality less than 6% 1.
From the Research
Transcarotid Artery Revascularization (TCAR) Overview
- TCAR is a novel carotid stenting method that uses a flow-reversal neuroprotection system to reduce the risk of embolic events during carotid intervention 2.
- It has been shown to have a lower risk of stroke or death compared to the transfemoral carotid stenting approach, and an equivalent risk of stroke or death compared to traditional carotid endarterectomy 2, 3.
Benefits of TCAR
- Lower risk of myocardial infarction, cranial nerve injuries, and shorter operative times compared to endarterectomy 2.
- High technical success rates, with low perioperative stroke, myocardial infarction, and mortality rates 3, 4.
- Significantly associated with a lower in-hospital stroke/transient ischemic attack rate when compared to transfemoral carotid stenting 3.
Technical Aspects of TCAR
- Allows for a proximal neuroprotection strategy based on flow reversal, unlike transfemoral carotid angioplasty and stenting 5.
- Uses the ENROUTE Transcarotid Neuroprotection System to afford cerebral protection from embolization without manipulation of the internal carotid artery stenotic lesion 4.
- Can be performed under local or general anesthesia, with no significant difference in clinical outcomes between the two 6.
Outcomes of TCAR
- Excellent outcomes have been observed in patients undergoing TCAR, with low rates of postoperative stroke, myocardial infarction, and mortality 3, 4, 6.
- No significant differences in outcomes have been found between TCAR and carotid endarterectomy, although TCAR has a significantly lower risk of cranial nerve injury 2, 3.