Q&A: TCAR, which transformed carotid artery revascularization, reaches 100,000 procedures
Click Here to Manage Email Alerts
Key takeaways:
- There have now been more than 100,000 transcarotid artery revascularization procedures.
- The technology has improved the safety of carotid revascularization without compromising efficacy.
Revascularization of carotid arteries has always been a challenging procedure, and both carotid surgery and transfemoral carotid stenting can lead to severe complications.
Then, in 2015, the FDA approved the first transcarotid artery revascularization (TCAR) system (ENROUTE Transcarotid Neuroprotection System with ENROUTE Transcarotid Stent, Silk Road Medical). The system allows the physician direct access to the common carotid artery and to initiate high-rate temporary blood flow reversal to prevent the brain from stroke while delivering and implanting the stent. Pre- and postapproval studies showed the system’s safety and efficacy. In 2022, the FDA expanded the indication for TCAR to include patients at standard surgical risk; it was previously approved for patients at high surgical risk.
In July, Silk Road Medical announced that TCAR achieved a milestone with 100,000 procedures performed since its inception. Healio spoke with Brad Grimsley, MD, FACS, partner with Texas Vascular Associates and affiliated staff at Baylor Heart and Vascular hospitals, who has performed more than 500 TCAR procedures, about how TCAR changed revascularization of the carotid arteries, which patients are appropriate for it and how they benefit from it and what the future of carotid artery revascularization might look like.
Healio: Before TCAR, how did you revascularize carotid arteries in most patients? What were the challenges there?
Grimsley: Before TCAR, carotid endarterectomy was the mainstay of therapy for extracranial cerebral vascular occlusive disease. This involves an open incision on the neck of about 8 cm to 10 cm with the complete carotid artery exposed, opened up, cleaned out, and a patch sewn in place to close the vessel. If patients are not a good candidate for an open procedure with general anesthesia, then they would be considered for a transfemoral carotid stent. A disadvantage for this type of stent procedure is increased risk for stroke, six times what it would be for a carotid endarterectomy. The disadvantages of open surgery would include cranial nerve injury and, more commonly, cardiac complications, such as procedural myocardial infarction.
Healio: How did TCAR change the process of revascularizing carotid arteries?
Grimsley: TCAR uses the best parts of carotid endarterectomy and the best parts of carotid stenting to eliminate, or at a minimum reduce, the risks associated with the other two procedures.
Healio: What are the biggest benefits of the TCAR procedure?
Grimsley: The biggest benefit of TCAR is the fact that the incision is much smaller than the traditional carotid cleanout procedure. Given this, patients are able to recover from surgery more quickly. Also, there’s not the risk associated with patch infection, which can also be seen with open cleanout surgery. In addition, because of the reversal of flow that is seen with a TCAR, there is significant reduction of the periprocedural stroke that is associated with traditional transfemoral carotid stenting.
Healio: Which patients are best suited for a TCAR procedure?
Grimsley: Patients who are at increased risk from having open surgery and prolonged anesthesia are particularly good candidates for TCAR. Those are typically patients with poor heart function or poor lung function. Also, patients who have had previous open carotid surgery who have a recurrence are particularly good candidates for TCAR. If a patient has an occlusion of the contralateral carotid artery, or they have a particularly high lesion beneath the jaw level, TCAR would be the treatment of choice.
Healio: How does the process work to determine if a patient should get TCAR or a different procedure?
Grimsley: Each patient who has been seen in the clinic is carefully evaluated to determine which of the three procedures best suits the patient: TCAR, carotid endarterectomy or transfemoral carotid stent. After looking at the risk factors associated with each one of the procedures, and also patients’ comorbidities, the most appropriate procedure for that patient is chosen. Of course, most patients weigh in on what they would like to have done after hearing the description and risks associated with each of the procedures, and most patients lean toward having a procedure that provides the best result with the least amount of risk. That’s why most patients are coming to the clinic asking for the TCAR procedure.
Healio: Are there any differences in how you performed your first TCAR procedures vs. how you perform them now?
Grimsley: After doing more than 500 TCAR procedures, the technique gets refined, and we have nicknamed the technique SWEET technique. We do it the Same Way Each and Every Time and expect the same great outcomes each and every time.
Healio: What do you think the future of carotid artery revascularization will look like?
Grimsley: I believe that most patients who come in to have their procedure want the least amount of surgery that is the most effective, and wish to get back to their daily activities as quickly as possible. For that reason, TCAR has become the treatment of choice in my practice and for most younger surgeons who have the skill set. As time goes on, I feel the future is bright for TCAR, as there is a movement in all procedures to be more minimally invasive.
Healio: Is there anything else you would like to mention?
Grimsley: I would like to mention that TCAR has turned out to be a great option for patients with a busy lifestyle who cannot afford time off work or activities. I think most people realize that life is short and they want to spend the least amount of time in the hospital recovering from surgery and more time being productive in their daily lives.
Reference:
- Silk Road Medical celebrates milestone of 100,000 transcarotid artery revascularization (TCAR) procedures. https://silkroadmed.com/wp-content/uploads/2024/07/AP01135.A-100K-Procedures_Press_Release.pdf. Published July 30, 2024. Accessed Aug. 19, 2024.
For more information:
Brad Grimsley, MD, FACS, can be reached at Texas Vascular Associates, PA, 621 N. Hall St., Suite 100, Dallas, TX 75226.
Collapse
Healio Interviews
Click Here to Manage Email Alerts