Transcarotid Revascularization (TCAR)

What is TCAR or transcarotid artery revascularization?

TCAR (transcarotid artery revascularization) is one of several procedures that repair blockages in your carotid artery.

A surgeon repairs carotid artery blockages in procedures called revascularization. There are several types of revascularization procedures.

Your surgeon might recommend an open surgery called carotid endarterectomy (CEA) to remove plaque.

Or your surgeon may recommend an angioplasty, which pushes plaque to the sides so blood can flow through more easily. After angioplasty, your surgeon places a stent within your carotid artery to open the blockage and cover the plaque in procedures called carotid stenting (CAS) or transcarotid revascularization (TCAR). In TCAR, your surgeon delivers the stent directly to your neck through a small incision. In CAS, they use a spot in your groin or arm.

What does TCAR treat?

The carotid artery is an artery in your neck that provides blood flow to your brain and face. The split or division of the carotid artery is a common spot in your body where plaque (fat, cholesterol and other substances) can build up, creating a narrowing or blockage. These blockages can lead to strokes when a piece of the blockage breaks off or the artery closes completely. TCAR — and CEA and CAS — are effective ways to treat carotid blockages and help to prevent strokes.

The U.S. Food and Drug Administration (FDA) approved transcarotid artery revascularization (TCAR) in 2015 as a new type of repair that combined a less invasive surgery approach and stenting for people at a higher risk of complications from CEA. The higher risk for CEA could be related to:

• Age.
• Heart disease.
• Lung disease.
• Scar tissue in your neck from prior surgery or radiation therapy.

You may also be at higher risk for complications from CEA if you have a high-level blockage in a hard-to-reach spot.

In 2022, CMS (U.S. Centers for Medicaid and Medicare) approved TCAR for people with a standard risk level. In other words, for people without other medical conditions.

How common is TCAR?

TCAR is becoming more common, with about 20,000 procedures performed to date in the United States. Currently, in the United States, surgeons do about 10% of all carotid repairs this way.

How should I prepare for a carotid revascularization procedure?

Before your TCAR carotid surgery, your healthcare provider will order tests. These may include:

• Blood tests.
• Ultrasound of your carotid artery.
• Computed tomography (CT) angiogram of your carotid artery and brain.

To prepare your body for the procedure, you’ll need to take medicines your provider prescribes (like a statin) and antiplatelet medicines (like aspirin and clopidogrel).

Your provider will ask you not to eat or drink anything after midnight the night before your carotid artery revascularization procedure.

What happens during TCAR?

In an operating room, your surgical team will:

1. Give you local or general anesthesia.
2. Put a tube into a vein in your femoral vein in your groin to bring filtered blood back into your body.
3. Make a cut (1 to 1.5 inches, also called an incision) in your neck just above your collarbone on the side that needs fixed.
4. Place a tube through that small incision into your carotid artery. They clamp the artery before the tube, which connects to a device that filters your blood for any pieces of plaque. After the filter, the tube also connects to the tube in your femoral vein. During this time, the flow to your brain comes from the other side and arteries to the back of your brain (vertebral arteries).
5. This connection allows surgeons to temporarily change the direction of the blood flow in your carotid artery away from your brain. While they treat the blockage, any debris or particles that break off are filtered before returning to your vein. This stops the risk of a stroke during the repair.
6. Your surgeon uses a wire to cross the narrowing in your artery. Then, they use a balloon to temporarily stretch open the blockage.
7. They then place a metallic stent into your carotid artery to hold the artery open and trap the blockage in place.
8. They remove the tubes and then suture the small opening in your artery closed. Then, they close the incision in your neck.

The whole procedure takes about 1 and a half hours.

What happens after TCAR?

You can expect to stay overnight at the hospital after your TCAR procedure. Healthcare providers will keep checking on you to monitor your recovery.

What are the advantages and disadvantages of TCAR?

TCAR offers some advantages over CEA and CAS. For example, crossing your body to get to the artery in your neck can be difficult due to curves or disease. In some cases, this increases the risk of stroke. TCAR may also have advantages over CEA if you have a blockage under your jaw or high in your neck, or if you’ve had prior neck surgery.

TCAR approach also has some limitations. If the vessel is very hardened with calcium, a stent might not be able to hold the blockage open. In this case, CEA is best. TCAR also isn’t a good option if your artery has blockages before the brain branch (common carotid artery) or it’s very tortuous (curved).

Researchers haven’t directly compared TCAR and CEA, but they seem to carry a similar risk of stroke. CAS has a slightly higher risk of minor stroke than TCAR or CEA, but CAS has lower heart attack risks.

What are the benefits of TCAR?

Carotid revascularization lowers your risk of having a stroke. As a minimally invasive procedure, TCAR provides these additional advantages:

• Leaves a smaller scar on your neck.
• Has a lower risk of nerve damage than CEA.
• May be a safer way to place a stent when the arteries in your chest or at the base of your neck are tortuous or diseased.

How successful is carotid revascularization?

Because TCAR is a newer procedure, providers don’t have information on long-term results. And it hasn’t been studied in direct comparison to CEA. But TCAR appears to be as safe as CEA or CAS with excellent outcomes.

What are the risks or complications of TCAR?

Like other types of carotid revascularization, TCAR carries a risk of:

• Injury of your carotid artery.
• Bleeding around your neck wound.
• Swelling around the cut in your neck.
• Nerve damage.
• Stroke.
• Heart attack.
• Death.

What is the recovery time?

Because TCAR is a minimally invasive procedure, you don’t have large cuts that need to heal. But you shouldn’t do any heavy lifting for a week or more. Talk with your provider about when you can return to work and other activities. You’ll also need to look at the incision in your neck every day to make sure it’s healing well and isn’t infected.

Living with a TCAR stent

After you go home and recover, you can help keep your carotid artery from narrowing again by:

• Avoiding tobacco products.
• Exercising regularly.
• Eating foods low in saturated fats.
• Taking medicines your provider prescribes to prevent blood clots and lower cholesterol.

When should I call my healthcare provider?

Contact your healthcare provider if you have signs of an infection in your wound, like:

• Fever.
• Chills.
• Redness around your wound.
• Fluid coming out of your wound.

A note from Cleveland Clinic

If you need carotid revascularization, your healthcare provider will need to decide which approach to take. Don’t be afraid to ask questions about the different procedures your provider is considering. You should feel comfortable with the choice of procedure. No matter which procedure you have, be sure to go to all your follow-up appointments for the best results.