From the Guidelines
Transcarotid artery revascularization (TCAR) is primarily indicated for patients with significant carotid artery stenosis who are at high risk for complications from traditional carotid endarterectomy (CEA), with a technical success rate of 99.7% and low 30-day complication rates reported in large registry-based analyses 1.
Indications for TCAR
The indications for TCAR include:
- Symptomatic patients with ≥50% stenosis or asymptomatic patients with ≥70% stenosis who have anatomical or physiological high-risk features, such as previous neck radiation, previous neck surgery, contralateral carotid occlusion, high cervical lesions, recurrent stenosis after prior CEA, severe cardiopulmonary disease, or age >80 years.
- Patients with a hostile neck anatomy that would make traditional surgical access challenging.
Benefits of TCAR
TCAR combines the benefits of both surgical and endovascular approaches, offering:
- A lower stroke risk than transfemoral carotid artery stenting
- A less invasive procedure than CEA
- The flow reversal system used during TCAR provides cerebral protection by temporarily redirecting blood flow away from the brain during the intervention, reducing the risk of procedural embolic events.
Comparison with Other Procedures
According to the 2024 ESC guidelines, TCAR has been shown to have a 1-year rate of stroke or death of 6.4%, compared to 5.2% for CEA and 9.7% for transfemoral carotid artery stenting (TFCAS) 1.
Antithrombotic Therapy
The use of antithrombotic therapy, such as DAPT with low-dose aspirin and clopidogrel, is recommended for all patients with symptomatic carotid stenosis for at least 3 months, and for those undergoing endovascular revascularization, DAPT should be continued for 4 weeks after the procedure 1.
From the Research
Indications for Transcarotid Artery Revascularization
The indications for Transcarotid Artery Revascularization (TCAR) include:
- Carotid artery stenosis, particularly in patients with high-risk medical comorbidities or challenging surgical anatomy 2, 3, 4
- Symptomatic or asymptomatic extracranial carotid artery stenosis, with a stenosis of 50% or greater for symptomatic patients and 80% or greater for asymptomatic patients 5
- Patients who are at high risk for carotid endarterectomy (CEA) or transfemoral carotid artery stenting (TFCAS) 3, 6
Patient Selection
Patient selection for TCAR is crucial, and the following factors should be considered:
- Age: TCAR can be performed in patients aged 80 years or older, with no significant difference in outcomes compared to younger patients 5
- Medical comorbidities: TCAR is suitable for patients with high-risk medical comorbidities, such as coronary artery disease, chronic heart failure, chronic obstructive pulmonary disease, and chronic kidney disease 2, 3
- Carotid symptomatology: TCAR can be performed in both symptomatic and asymptomatic patients 5
- Anatomical considerations: TCAR is suitable for patients with challenging surgical anatomy, such as those with prior neck radiation or surgery 4
Benefits of TCAR
The benefits of TCAR include: