Transcarotid Artery Endovascular Revascularization
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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:
Indications:
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 :
Medical Indications:
- Age > 75
- CHF
- LVEF < 35%
- >2 diseased coronaries w/ 70% stenosis
- Unstable angina
- MI within 6 weeks
- Abnormal stress test
- Need for open heart surgery
- Need for major surgery (including vascular)
- Uncontrolled diabetes
- Severe pulmonary disease
- 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 |
Labs and studies
Operating room setup
Patient preparation and premedication
Regional and neuraxial techniques
Intraoperative management
Monitoring and access
Induction and airway management
Positioning
Maintenance and surgical considerations
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Procedure variants
| Variant 1 | Variant 2 | |
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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.