From the Guidelines
TCAR is indicated for patients with symptomatic carotid stenosis of 70%–99% who are at high risk for traditional carotid endarterectomy (CEA) or have anatomical or physiological high-risk features, as supported by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. The primary considerations for TCAR include the degree of stenosis, symptoms, and the patient's risk profile for CEA. According to the guidelines, for symptomatic patients at high risk for CEA with a 70%–99% ICA stenosis, CAS (which includes TCAR as a method of carotid artery stenting) should be considered provided a documented 30-day risk of procedural death/stroke is <6% 1. Key points to consider for TCAR indications include:
- Symptomatic carotid stenosis of 70%–99% in patients at high risk for CEA
- Anatomical or physiological high-risk features such as previous neck radiation, previous neck surgery, contralateral laryngeal nerve palsy, restenosis after prior carotid intervention, surgically inaccessible lesions, and significant medical comorbidities
- Elderly patients who may not tolerate the physiological stress of CEA
- Patients with unstable plaques or heavy calcification, where the flow reversal technique in TCAR can minimize the risk of embolic stroke The decision to proceed with TCAR should be made after a multidisciplinary evaluation considering the patient's anatomical factors, comorbidities, and life expectancy, as well as the potential benefits and risks of the procedure compared to alternative treatments like CEA or transfemoral carotid artery stenting 1.
From the Research
Indications for Transcarotid Artery Revascularization (TCAR)
The indications for TCAR are based on the treatment of symptomatic carotid stenosis, particularly for patients who are at high risk for carotid endarterectomy (CEA) or carotid artery stenting (CAS) [ 2, 3,4,5 ]. The key indications include:
- Symptomatic internal carotid artery disease [ 3 ]
- Significant symptomatic carotid stenosis [ 2 ]
- Patients who are at high risk for CEA or CAS, such as those with hyperlipidemia, chronic obstructive pulmonary disease, or older age [ 4, 5 ]
Anatomic Eligibility for TCAR
The anatomic eligibility for TCAR is based on specific criteria, including:
- ICA diameter of 4-9 mm
- Common carotid artery (CCA) diameter of ≥6 mm
- Clavicle to carotid bifurcation distance of ≥5 cm
- Lack of significant CCA puncture site plaque [ 4 ]
Comparison with Other Treatments
TCAR has been compared to CEA and CAS in terms of safety and efficacy, with studies suggesting that TCAR may have similar outcomes to CEA, regardless of patient risk status [ 5 ]. Additionally, TCAR may have some advantages over CAS, such as lower mortality rates [ 3 ].
Novel Applications of TCAR
TCAR has also been explored as a treatment option for intracranial carotid artery stenosis, with a small case series demonstrating the feasibility of this approach [ 6 ]. This novel application of TCAR may offer a new treatment option for patients with surgically inaccessible intracranial disease.