Trans Carotid Artery Revascularization

Carotid Artery Stenosis (CAS), or blockage in the carotid artery, is a considerable risk for strokes or TIAs. Trans Carotid Artery Revascularization, or TCAR, is a novel technique to treat CAS by accessing the common carotid artery via a small incision just above the collar bone. The older stenting technique requires access to the carotid artery via the femoral artery in the upper leg and navigating a metal wire going upstream of the blood flow to the carotid artery in the neck. In both techniques, a metal umbrella-like stent opens up to keep blood flowing through the artery. The TCAR procedure also utilizes a special tool that reverses the blood flow that usually goes from the aorta to carotid and to the brain. The back flow of blood brings pieces of plaque back through a filter and then plaque-free blood returns to a vein in the leg to be recycled by the heart. In the transfemoral approach, there is a risk that using this tool to reverse blood flow would cause lack of blood flow to other arteries. The brain is unique because even if one artery is blocked, there are 3 others that continue to
supply the brain with oxygenated blood. Therefore, even with the decreased blood flow in the carotid artery that is being operated on, the brain will continue to receive plenty of blood. An advantage of TCAR over the transfemoral stent is a decreased risk of having a piece of plaque travelling up to the brain and causing a stroke, though the risk of this varies with patient’s risk factors1. TCAR and the surgical removal of the plaque (Carotid Endarterectomy) are equally as efficacious in one-year follow-up2. In-hospital complications for either procedure are rare (<1% for both)1. Patients undergoing TCAR have an increased risk of developing hypotension after the procedure in comparison to CEA2. In the end, TCAR is a new method to treat carotid artery stenosis that is equally as efficacious as other surgical interventions in preventing long-term strokes/death from clots broken off of the plaque in the carotid artery. It offers decreased risk of stroke/TIAs during the time when the stent is placed as compared to a transfemoral approach. The patient, in discussion with a vascular surgeon, will take into account many aspects of a patient’s history in order to assess which procedure is best. 

The following video is a representation of the procedure: TCAR (Transcarotid Arterial Revascularization)

References
1. Schermerhorn ML, Liang P, Eldrup-Jorgensen J, et al. Association of Transcarotid Artery Revascularization vs Transfemoral Carotid Artery Stenting With Stroke or Death Among Patients With Carotid Artery Stenosis. JAMA. 2019;322(23):2313-2322. doi:10.1001/  jama.2019.18441.
2. Malas M, Dakour-Aridi H, Kashyap V, et al. Outcomes of TransCarotid Revascularization with Dynamic Flow Reversal (TCAR) Versus Carotid Endarterectomy (CEA) in the TCAR Surveillance Project. European Journal of Vascular & Endovascular Surgery. 2019;58:e638. https://search-ebscohost-com.proxy.rvu.edu/login.aspx? direct=true&db=edo&AN=141107250&site=eds-live&scope=site. Accessed March 10, 2020.