By Marti Webb Slay 

Interventional cardiologists are more often choosing transcarotid artery revascularization (TCAR) over carotid endarterectomy or transfemoral carotid artery stenting to treat obstructive carotid artery disease, according to James Trimm, MD,  interventional cardiologist at Birmingham Heart Clinic. 

TCAR, originally approved in 2015, has been approved for more patients over time. “Our option is TCAR first, endarterectomy or transfemoral stenting second,” Trimm said. “Most interventional cardiologists opt for TCAR first, whereas a vascular surgeon may choose endarterectomy first.

“Carotid endarterectomy is an open surgery which for many years was the standard of care. It’s a good procedure, but it’s the most invasive. A surgeon does a cut down to the artery, exposes the artery and then removes the plaque. The surgeon then sews the artery closed and sews the skin back closed. That was the only option for many years.” 

Transfemoral carotid stenting is another treatment option, but for years it has been limited to patients who are too high risk for surgery or was used for patients in clinical trials.  

Trimm sees TCAR as a hybrid of stenting and endarterectomy. “What makes TCAR so attractive is that it has a smaller incision, a faster recovery, the same or less risk of stroke, and it’s cost effective compared to surgery and stenting, and is also a quicker procedure to do than either endarterectomy or stenting through the groin,” he said. 

TCAR reverses blood flow during the procedure, pulling debris away from the brain and lowering the risk of stroke. “What makes it a better procedure is that you put a sheath in the femoral vein in the groin, and you are reversing blood flow,” Trimm said. “One sheath is in the artery in the neck, and the other is in the vein in the leg. The pressure difference causes reversal of flow. That’s why there is such a low risk of stroke.

“Filters have lowered the risk of stroke in transfemoral stenting and therefore improved the outcomes in stenting, but the manipulation of the catheter, the filter, and the stent increased the risk of stroke. TCAR eliminates these issues, which is why it is rapidly being accepted as the go-to procedure and may soon become the standard of care.”

While a number of patients come to Trimm with some testing done by the referring physician, others are sent to his practice in order for him to do the testing, interpret the data, and determine the course of care. “TCAR has the same indications as endarterectomy or transfemoral stenting” he said. “Usually if a patient has blurred vision in one eye or weakness on one side, they get a carotid doppler, and it is sent to us to interpret. Classic Indications are people who have symptomatic obstructive carotid artery with narrowing of 70 percent or greater.”

There are certain anatomical requirements for choosing the TCAR procedure. “The length between the clavicle and where the blockage is has to be greater than 50 mm,” Trimm said. “In TCAR, you go through the common carotid artery vs the femoral artery, and you have to have a place to land the delivery sheath. 

“The TCAR surgery is still considered inpatient, requiring an overnight stay. In my opinion, that’s a purely insurance-driven decision. All carotid procedures are still coded as inpatient procedures. The patients are awake and mobile and doing quite well the day of the procedure. Most patients could go home the same day.” 

Following the procedure, Trimm sees his patients with a carotid doppler a month after the procedure, and he typically follows up with a carotid doppler every six to 12 months. He has found that the rate of reoccurrence is lower when compared to the transfemoral approach. 

“Typically, the patient will be on dual anti-platelet therapy and cholesterol-lowering medicine ten to14 days before and 30 days after the procedure. One of the anti-platelet medicines is typically discontinued after 30 days,” he said. 

Trimm believes TCAR will soon become the standard of care for carotid artery disease. His practice is approaching 200 of the procedures, and he anticipates that number will continue to grow.