Transcarotid Artery Revascularization – TCAR
is much improved from Transfemoral carotid stenting
How successful is Transcarotid artery revascularization / TCAR in revascularizing the carotid artery?
Transcarotid artery revascularization (TCAR) has been successful in revascularizing (opening stenosis or narrowing) the carotid artery, providing promising outcomes for patients with carotid stenosis. Studies have shown that TCAR is comparable to carotid endarterectomy (CEA) in terms of long-term efficacy and consistently produces positive results regardless of patient risk status. Various clinical trials and initiatives, such as the ROADSTER multicenter trial and the Society for Vascular Surgery Vascular Quality Initiative, have demonstrated the success of TCAR.
TCAR has become the primary approach for carotid revascularization in high-risk patients, surpassing transfemoral and CEA in popularity and usage. Its success lies in its favorable outcomes, low complication rates, cost-effectiveness, and increasing utilization. Therefore, TCAR should be considered an important option in the treatment of carotid stenosis.
How is TCAR performed?
Transcarotid artery revascularization (TCAR) is a minimally invasive procedure used to treat carotid stenosis. The surgeon accesses the carotid artery through a small neck incision and uses a specialized system called flow reversal to temporarily reverse blood flow, protecting the brain from debris and reducing the risk of stroke. Once blood flow is reversed, a stent is placed to widen the narrowed artery and improve blood flow.
One advantage of TCAR is its ability to be performed when transfemoral access is not possible due to anatomical abnormalities. TCAR allows for effective recanalization of occluded blood vessels by bypassing anatomical obstacles. It has been found to be a cost-effective option compared to carotid endarterectomy in some cost-effectiveness analyses.
What is the difference between TCAR and transfemoral carotid stenting?
TCAR involves accessing the carotid artery through a small incision in the neck, while transfemoral involves accessing it through an incision in the groin or leg.
Key differences between TCAR and transfemoral include:
1. Approach: TCAR uses a direct approach to the blocked artery, reducing the risk of debris reaching the brain, while transfemoral uses a catheter threaded through an incision in the groin or leg.
2. Periprocedural stroke risk: TCAR has shown low rates of periprocedural neurologic events, myocardial infarction, and death, with outcomes comparable to carotid endarterectomy (CEA). transfemoral may carry a higher risk of periprocedural stroke compared to TCAR.
3. Patient selection: TCAR is increasingly used for high-risk patients, while transfemoral is less invasive but may be associated with higher stroke risk.
Overall, TCAR and transfemoral have their own benefits and risks that should be considered based on individual patient characteristics and anatomical considerations. TCAR has gained popularity as a primary approach for high-risk patients.
What are the potential risks associated with transfemoral carotid stenting?
Transfemoral carotid stenting, a procedure used to treat carotid artery disease, carries potential risks that should be considered. Some of the risks associated with this procedure include:
In an article published by the Cochrane Review, Müller MD, Lyrer P, Brown MM, Bonati LH. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Cochrane Database of Systematic Reviews 2020, Issue 2:
1. We included 22 trials involving 9753 participants. In participants with symptomatic carotid stenosis, compared with endarterectomy, (transfemoral) stenting was associated with a higher risk of periprocedural death or stroke.
2. In participants with asymptomatic carotid stenosis, there was a non-significant increase in periprocedural death or stroke with (transfemoral) stenting compared with endarterectomy.
3. Myocardial infarction: Transfemoral carotid stenting carries a risk of in-hospital myocardial infarction; The combination of periprocedural death or stroke or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favored endarterectomy.
Other risks include:
4. Complexity of aorta anatomy: The complexity of aortic arch anatomy can influence the outcomes of transfemoral carotid artery stenting.
5. Anatomic eligibility: Patient anatomy, comorbidities, and overall health need to be considered to determine the most suitable approach for either TCAR or transfemoral carotid artery stenting and endarterectomy.
6. With less transfemoral procedures performed means less technical experience with complications.
What are the benefits of TCAR compared to transfemoral carotid stenting?
Transcarotid artery revascularization (TCAR) offers several benefits compared to transfemoral carotid stenting for treating carotid stenosis. These benefits include improved perioperative outcomes, regardless of patient risk or symptom status, and degree of stenosis. TCAR has shown superior outcomes in octogenarians. Operator experience plays a role in Transfemoral stenting outcomes, highlighting the importance of considering the expertise of the operator. TCAR has low rates of periprocedural neurologic events, myocardial infarction, and death. It has expanded indications approved by the FDA and is cost-effective.
What is the success rate of TCAR?
The ROADSTER multicenter trial highlighted the excellent one-year durability of TCAR with dynamic flow reversal, suggesting promising long-term effectiveness.
The overall stroke rate of 1.4% is the lowest reported to date for any prospective multi-center trial of carotid stenting.
In a comparative study between TCAR and Transfemoral stenting,
Among patients undergoing treatment for carotid stenosis, trans carotid artery revascularization, compared with transfemoral carotid artery stenting, was significantly associated with a lower risk of stroke or death.
How does TCAR improve a patient’s overall outcome?
Transcarotid artery revascularization (TCAR) improves a patient’s overall outcome in several ways.
1. TCAR is a minimally invasive procedure that directly treats carotid artery stenosis, providing favorable outcomes.
2. Studies have shown that TCAR is effective in high-risk patients, with low rates of neurologic events, myocardial infarction, and death.
3. TCAR has comparable outcomes to carotid endarterectomy (CEA), previously considered the standard treatment.
4. It benefits patients regardless of risk status, showing similar results to CEA regardless of symptoms or stenosis degree among octogenarians.
5. From 2015 to 2019, there was a significant shift towards TCAR utilization, highlighting its recognized benefits over other methods.
In summary, TCAR improves overall patient outcomes by providing a minimally invasive approach, reducing complications, and offering comparable results to established treatments. It benefits various patient populations, including high-risk individuals, and has become a primary approach for carotid stenting in healthcare.