From the Guidelines
Transcarotid artery revascularization (TCAR) is primarily indicated for patients with 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, as reported in large registry-based analyses 1.
Indications for TCAR
The indications for TCAR include:
- Patients with significant carotid stenosis (typically >70% in symptomatic patients or >80% in asymptomatic patients) who have anatomical or physiological factors that increase surgical risk, such as a hostile neck from previous surgery or radiation, contralateral carotid occlusion, high carotid bifurcation, short neck, obesity, or medical comorbidities that increase perioperative risk such as severe cardiac or pulmonary disease.
- Patients with recurrent stenosis after previous carotid intervention.
- Elderly patients or those with challenging aortic arch anatomy, as TCAR may reduce the risk of perioperative stroke compared to transfemoral carotid artery stenting.
Benefits of TCAR
The benefits of TCAR include:
- Using flow reversal to protect the brain from emboli during stent placement.
- Accessing the carotid artery directly through a small incision at the base of the neck.
- Avoiding manipulation of the aortic arch.
- Combining the benefits of surgical access with endovascular treatment, potentially reducing the risk of perioperative stroke.
Decision to Perform TCAR
The decision to perform TCAR should be individualized based on patient characteristics, anatomical considerations, and the expertise of the treating physician, taking into account the patient's comorbid conditions, life expectancy, and other individual factors, as well as a thorough discussion of the risks and benefits of the procedure with an understanding of patient preferences 1.
From the Research
Indications for Transcarotid Artery Revascularization
- Transcarotid artery revascularization (TCAR) is indicated for patients with high-risk medical comorbidities and those with challenging surgical anatomy 2
- TCAR is used for the treatment of patients with symptomatic (≥50%) or asymptomatic (≥80%) extracranial carotid artery stenosis 3
- The procedure is suitable for elderly patients, including those aged ≥80 years, with no significant difference in outcomes compared to younger patients 3
- TCAR is used as an alternative to carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS) for carotid revascularization 4, 5
- Patient risk status is the most important characteristic associated with the use of TCAR compared to CEA and TFCAS 5
Patient Selection
- Patients at high risk for stroke, cranial nerve injury, or major cardiac event are suitable candidates for TCAR 5
- Elderly patients, including those aged ≥80 years, can undergo TCAR with no significant difference in outcomes compared to younger patients 3
- Patients with symptomatic or asymptomatic carotid artery stenosis can be treated with TCAR 3
Benefits of TCAR
- Lower risk of stroke or death compared to TFCAS 2
- Equivalent risk of stroke or death compared to CEA 2
- Lower risk of myocardial infarction, cranial nerve injuries, and shorter operative times compared to CEA 2
- Technical success can be achieved in all cases, with no incidence of cerebrovascular ischemic event, MI, cranial nerve injury, or mortality through 30 days after procedure 3, 6