TCAR, or Not TCAR, That Is the Question: Review of Current Transcarotid Artery Revascularization Data

Purpose: Understand transcarotid artery revascularization (TCAR) indications and contraindications in carotid vascular disease. Review current data regarding TCAR.

Materials and Methods: Stroke is the fifth leading cause of death in the United States, contributing up to 142,000 deaths annually and many more with long-term disability. Carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS) have been the standard in treating carotid vascular disease. Recent development of TCAR has evolved the management of carotid disease, using direct carotid access with flow reversal via arteriovenous shunting through the femoral vein. This review discusses current data available for TCAR.

Results: Evidence for TCAR has been developing rapidly. ROADSTER, a prospective clinical trial of 165 participants, had an average flow reversal time of 12.9 minutes and a 2.5% 30-day stroke, death, or myocardial infarction (MI) rate. At 1-year follow-up, 0.6% of patients had an ipsilateral stroke, and 4.2% of patients had died. The following postmarket study, ROADSTER 2, had 632 participants with a similar 1.7% stroke, death, or MI rate. Schermerhorn et al retrospectively compared 1182 TCAR cases with 10,797 CEA cases, with data showing no statistical difference in periprocedural stroke rate (1.4% vs. 1.2%), in-hospital death rate (0.3% vs. 0.3%), and 30-day death rate (0.9% vs. 0.4%). The PROOF study, a prospective, single-arm, open-label study, examined 75 patients, resulting in technical success rate of 90.6% and average reverse flow time of 19.1 minutes. Of these patients, 6.7% had a transient altered level of consciousness during flow reversal, and 10 patients had new ipsilateral diffusion restriction lesions on postprocedure diffusion-weighted imaging. Last, Schermerhorn et al examined 5250 cases from 2016 to 2019 in the Vascular Quality Initiative TCAR Surveillance Project (VQI-TSP) and showed a 1.6% in-hospital stroke, death, or MI rate.

Conclusions: Management options of carotid vascular disease continues to evolve, with CEA, TF-CAS, and now the most novel, the innovative TCAR procedure. This review provides current data to help guide patient selection for transcarotid artery revascularization.