Froedtert & the Medical College of Wisconsin Froedtert Hospital is the first center in eastern Wisconsin to introduce a groundbreaking procedure, transcarotid artery revascularization, or TCAR, to reduce the risk of stroke during carotid artery stenting.
With up to 30% of strokes attributed to severe carotid artery blockages, TCAR is an innovative addition to treatment options to help prevent stroke that include medical management, carotid endarterectomy, carotid angioplasty and stenting.
Both endarterectomy and stenting, however, present the potential complication of a stroke during the procedure itself. Stenting, which up to now has been limited to symptomatic patients or those who have previously had a stroke, carries a higher risk than surgery.
“For carotid stenting, depending on the study you read, stroke risk from the procedure is as high as 15%,” said Peter Rossi, MD, chief of the Division of Vascular and Endovascular Surgery and MCW faculty member.
Reversing blood flow protects the brain
TCAR is a clinically proven, less invasive procedure designed to protect the brain from micro- and macro-emboli. The key to TCAR effectiveness is temporarily reversing blood flow in the carotid artery. Conventional stenting places a protective filter upstream of the blockage prior to angioplasty to catch any dislodged plaque; however, the protective device must first be advanced across the blockage, during which time plaque can break loose and cause a stroke. TCAR reverses blood flow away from the brain to guard against any debris that may be loosened, and the flow reversal starts before the blockage is touched.
The TCAR procedure begins with a small incision at the base of the neck, above the collarbone, to expose the carotid artery. A sheath is inserted into the artery that connects through an external filter to another sheath placed in the patient’s femoral vein. Blood flow is then reversed from the high-pressure carotid artery to the low-pressure femoral vein. Surgeons use pre-op ultrasound and CT scans and intraoperative fluoroscopy (X-rays) with contrast during TCAR to guide them to the blockage site.
“While the blood flow is reversed, we go across the blockage with a wire and put in a stent,” Dr. Rossi said. “We don’t touch the blockage until the blood flow is reversed.” Blood flow is reversed for only about eight to 10 minutes, and other arteries supply blood to the brain through the circle of Willis.
Fast recovery, favorable results
The TCAR procedure takes about an hour and requires only local anesthesia. “It’s definitely a fast recovery, and the complication rate is very low,” Dr. Rossi said. Froedtert & MCW physicians perform TCAR as a team, with both an endovascular surgeon and a vascular and interventional radiologist present. “It’s better for the patient that way ,” Dr. Rossi said. “It’s always beneficial to have more eyes and experience around the procedure.”
Recently, Dr. Rossi and Robert Hieb, MD, vascular and interventional radiologist and MCW faculty member, performed TCAR on a 67-year-old man with a carotid artery that was about 70% blocked. The patient qualified for TCAR because his carotid artery divided above the angle of the mandible, posing a higher risk of nerve injury. “I was up and about right away, and it didn’t even leave a scar,” the patient said. “I don’t feel light-headed anymore.”
TCAR is approved for high-risk patients who are not ideal candidates for traditional carotid endarterectomy.
“TCAR benefits people who have had previous neck surgery or radiation, or those with blockages that go up behind the angle of the jaw, which are tough to get to, or other problems that make it difficult for general anesthesia,” Dr. Rossi said.
For patients without these risk factors, carotid endarterectomy remains the standard of care. “The choice of managing carotid artery disease with surgery, stenting or medical therapy depends on individual patient risk factors,” Dr. Rossi said, adding that patients with carotid artery disease are also likely to have atherosclerosis elsewhere. “We have to treat the whole patient, not just one artery.”
