An evolution in carotid care: Contemporary TCAR data and optimization techniques

Abstract

ObjectiveCarotid endarterectomy (CEA) is the gold standard for revascularization of atherosclerotic extra-cranial carotid artery lesions. The introduction of transfemoral carotid artery stenting (TFCAS) led to multiple randomized controlled trials to compare the safety and efficacy of an endovascular approach against traditional CEA in the management of carotid artery stenosis. The operative management of carotid artery stenosis continues to evolve, with the more recent introduction of TransCarotid artery revascularization (TCAR) and a novel flow-reversal neuroprotection system. This manuscript reviews a brief history regarding carotid artery revascularization, as well as the indications, technical considerations, and clinical outcomes of the TCAR procedure. Technical considerationsThe preoperative, intraoperative, and postoperative medical and technical considerations are explored. Topics of discussion will include the indications and contraindications for TCAR, anatomic requirements, instructions for use (IFU) and off-label utility, optimal pharmacologic regimen with carotid stent placement, standard deployment and suggestions for hostile anatomy, as well as recommended postoperative management and surveillance imaging. DiscussionThe Society for Vascular Surgery (SVS) has published a consensus statement on the pathways available to obtain clinical competency and maintain technical proficiency with TCAR. Meta-analyses reviewing the contemporary technical success and clinical outcomes of TCAR have demonstrated high rates of procedural success and low rates of stroke, myocardial infarction, and death. Studies have further illustrated comparable one-year rates of peri‑procedural stroke between TCAR and CEA, for asymptomatic and symptomatic carotid lesions, with both outperforming TFCAS. ConclusionManagement of extra-cranial carotid artery stenosis utilizing TCAR with the ENROUTE flow-reversal neuroprotection system has been widely adopted, yielding clinical outcomes and stroke prevention similar to traditional CEA and superior to TFCAS.