Transcarotid Artery Endovascular Revascularization

Transcarotid Artery Endovascular Revascularization

Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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Also referred to as a TCAR, a transcarotid artery endovascular revascularization is an alternative to carotid endarterectomy for the management of carotid stenosis in patients who are determined to be poor open repair candidates based on high surgical risk or lesion location (distal lesions). Transcarotid artery revascularization (TCAR) is an alternative to trans-femoral stenting and is meant to decrease the risk for micro-embolic strokes through flow reversal through the carotid during stent placement (see below).

Overview

Surgical procedure:

The common carotid artery (CCA) is exposed via a small incision superior to the clavicle.

A flexible sheath is inserted into the CCA proximal to the lesion being stented and the distal end (outside the vessel) is connected to a flow reversal system (FRS).

At the same time the femoral vein is also being accessed either percutaneously or via surgical exposure, and a 2nd flexible sheath is inserted. The extraluminal end of the femoral sheath is attached to the other end of the flow reversal system (FRS).

Once connected blood flow from the high pressure CCA to the low pressure femoral vein through the FRS. After flow reversal wires are threaded past the lesion, if indicated pre-dilation of the vessel with balloon angioplasty occurs at this time, followed by deployment of the intralumenal stent. The FRS acts as a filter removing any plaques or disrupted intralumenal, decreasing the risk of micro-embolic strokes.

After successful placement, flow reversal is turned off and blood flow resumes in its normal direction. Sheaths removed and arteriotomy closed.

Video with overview of steps: TCAR | TransCarotid Artery Revascularization Procedure Narrated Animation | Silk Road Medical | https://www.youtube.com/watch?v=MI2s4rv0dJA

Indications:

Goal restoring laminar blood flow through a stenotic carotid artery narrowed by atherosclerotic or neointimal hyperplastic disease.

Decision to stent vs open repair depends on level of either surgical or CV risk. Any one of the following qualify a patient for high-risk status :

Criter

Medical:

• Age > 75
• Congestive Heart Failure
• LVEF < 35%
• >2 diseased coronaries w/ 70% stenosis
• Unstable angina or abnormal stress test
• MI within 6 weeks
• Need for additional open heart surgery
• Need for major surgery (including vascular)
• Uncontrolled diabetes
• Severe pulmonary disease

Anatomic:

• Prior head/neck surgery or irradiation
• Spinal immobility  
• Restenosis post CEA
• Surgically inaccessible lesion
• Laryngeal palsy; Laryngectomy
• Permanent contralateral cranial nerve injury
• Contralateral occlusion
• Severe tandem lesions
• Bilateral stenosis requiring treatment

Preoperative management

Patient evaluation

System	Considerations
Airway
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position	Supine
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

1.) Columbo JA, Martinez-Camblor P, O’Malley AJ, et al. Association of Adoption of Transcarotid Artery Revascularization With Center-Level Perioperative Outcomes. JAMA Netw Open. 2021;4(2):e2037885. doi:10.1001/jamanetworkopen.2020.37885

2.) Ankam A, Kinthala S, Madabhushi P. Anesthetic Considerations for Transcarotid Artery Revascularization: Experience and Review of Forty Cases From a Single Medical Center. Cureus. 2020 Dec 24;12(12):e12250. doi: 10.7759/cureus.12250. PMID: 33505816; PMCID: PMC7822093.

3.) Silk Road Medical. TCAR surveillance project. Accessed January 1, 2020. https://silkroadmed.com/tcar-surveillance-project/