Transfemoral Carotid Artery Stenting (TFCAS)

What is transfemoral carotid artery stenting?

Transfemoral carotid artery stenting (TFCAS) is a procedure to open a blocked carotid artery. A blockage can increase your stroke risk. But getting the right treatment lowers this risk and helps you get back to your routine.

Transfemoral carotid artery stenting is a minimally invasive procedure to place a stent (small mesh tube) into the narrowed artery section. The stent improves blood flow, lowering your risk of stroke from carotid artery disease. Because it’s minimally invasive, you can typically return to your usual activities within a few days.

When is it used?

You may need transfemoral carotid artery stenting if you have carotid artery disease. Carotid artery disease happens when plaque deposits (atheroma) of cholesterol and fat build up inside one or both carotid arteries. These blood vessels on each side of your neck carry blood to your brain, face and neck.

You probably won’t notice as plaque gradually collects inside an artery. But the plaque causes hardening of the arteries (atherosclerosis), which decreases blood flow to your brain. Plaque buildup also causes narrowing (stenosis) in your artery. Untreated carotid artery disease puts you at risk for transient ischemic attacks (TIAs or mini-strokes) and strokes.

Your provider may recommend transfemoral carotid artery stenting if you have carotid artery disease. Your overall health, your arteries’ shape and disease locations will determine if a stent is possible.

Sometimes, you may also have the option of a carotid endarterectomy (CEA) or transcarotid stent (TCAR). CEA is the most common treatment for carotid artery disease. But it requires making a larger incision in your neck and opening your carotid artery to remove plaque.

TCAR uses a stent but a provider delivers it through a tube put in your carotid artery through a small incision in the base of your neck.

Transfemoral carotid stenting uses a stent but a provider delivers it remotely from your groin or arm. It has had a higher non-disabling stroke risk than CEA or TCAR.

Transfemoral carotid artery stenting (TFCAS) may be a better option for you than CEA if you have one or more of these risk factors:

• Blockage in a hard-to-reach area
• Other conditions (comorbidities), like obesity, heart disease or lung disease
• Scar tissue in your neck from previous surgeries or radiation therapy
• Nerve damage to your vocal cord

Transfemoral stenting may be a better option for you than TFCAS if you have disease of the arteries in your chest (aortic arch) that lead to your carotid artery. TCAR has had similar outcomes to CEA, with lower rates of stroke than TFCAS in many studies.

How should I prepare for this procedure?

Before a TFCAS procedure, your provider may ask you to:

• Get blood tests and other health exams
• Get an echocardiogram or stress test to evaluate your heart
• Get imaging tests, like a carotid angiography, vascular ultrasound or magnetic resonance angiogram (MRA), to view the blockage
• Provide a list of the medications and supplements you take
• Take aspirin or other medications to prevent blood clots
• Fast (not eat or drink) for a certain amount of time before the procedure

What happens during transfemoral carotid artery stenting?

A provider with special training performs this procedure.

During the procedure, your care team will:

1. Give you anesthesia in most cases, but they may give you a small amount of medicine to relax you while you’re awake instead
2. Make a puncture in your groin
3. Guide a special catheter (tube) from your groin into your common carotid artery in your neck using a special X-ray machine
4. Place a filter away from the blockage to capture any debris or plaque that may break off when your artery expands
5. Insert a smaller catheter with a deflated balloon into the tube to reach the blockage
6. Inflate the balloon at the site of the blockage, pushing the plaque against your artery wall
7. Deflate and remove the balloon
8. Insert a self-expanding stent at the site of the blockage and expand it during placement, which stays there to keep your artery open, improving blood flow
9. Introduce a second, larger balloon to the area of the blockage and expand it to open your artery back to normal size
10. Deflate and remove the second balloon
11. Remove the filter
12. Remove the tube from your carotid artery and then from your groin or arm
13. Close the artery access site with a special device and hold pressure on the spot to allow your artery to seal

How long does this procedure take?

A transfemoral carotid artery stenting procedure takes less than two hours.

What happens after this procedure?

Here’s what typically happens after the TFCAS procedure:

1. A provider will monitor you in a recovery room for two to six hours and then in the hospital overnight.
2. You’ll receive medicine for discomfort.
3. Your provider will prescribe antiplatelet medicine to prevent blood clots from forming in the area with the stent.

What are the benefits of transfemoral carotid artery stenting?

Transfemoral carotid artery stenting improves blood flow to your brain, lowering your stroke risk. Because the procedure takes place through a small incision in your neck above the collarbone, you have less pain, scarring and infection risk. You can typically resume your usual activities in a few days.

What are the risks or complications of transfemoral carotid artery stenting?

Your provider will discuss the risks and complications associated with this procedure. The procedure has about a less than 3% risk of serious complications. Besides infection, bleeding or injury to a blood vessel, potential issues of TFCAS may include:

• Restenosis: There’s a slight risk of scar tissue forming under the stent. This scar tissue can cause the treated section to narrow again, restricting blood flow. This issue, in-stent restenosis, also happens with CEA.
• Stroke: Pieces of plaque can break off during the procedure and travel through your blood vessel. The embolic protection device helps catch these pieces, reducing stroke risk.
• Heart attack
• Death

What is the recovery time?

Most people can leave the hospital 24 hours after undergoing the procedure. You may have bruising, swelling and mild discomfort at the incision site for a few days. If you’re uncomfortable, talk to your provider about safe, over-the-counter pain medications to take.

You can usually begin to resume your activities 24 hours after transfemoral carotid artery stenting. During this time, avoid strenuous activities and heavy lifting.

What should I know about living with a carotid artery stent?

It’s important to take care of your health to lower your risk of future carotid artery disease problems. Try to:

• Eat heart-healthy foods
• Get help to stop using tobacco products
• Maintain a weight that’s healthy for you
• Stay physically active
• Take statins or other medications to lower your cholesterol

When should I call my healthcare provider?

Contact your healthcare provider if you experience:

• Fever or chills
• Nausea and vomiting
• Signs of infection at the incision site, like redness or yellow discharge
• Signs of stroke, like slurred speech, weakness (paralysis) or vision changes