TCAR vs. Traditional Surgeries: Is TCAR A Promising Innovation?

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Author: Sara Rachel Shajee Edited by: Ruchi Maniar

Every year, fifteen million people worldwide suffer from stroke. About six million people die and nearly five million are permanently disabled as a result of stroke. Up to a third of the cases predict carotid artery disease to be the source of stroke and there are 400,000 new diagnoses of carotid artery disease - blockage in the carotid arteries, which are responsible for supplying oxygenated blood to the brain - made every year in the United States alone.

Stroke, a pandemic disease, is the second leading cause of disability worldwide. The deadly disease has been researched for many years and only temporary treatment has been available to patients suffering from it. Combining the works of both science and technology in the field of medicine, the company Silk Road Medical introduced an innovative technique as a new treatment for patients with the risk of stroke due to carotid artery disease. Atlantic Health System's Overlook Medical Center became the first hospital in New Jersey, USA, to use this procedure.

The procedure known as TransCarotid Artery Revascularisation (TCAR) uses a neuroprotection system, which tentatively reverses the blood flow in arteries during surgical procedures such as carotid endarterectomy (an open surgical procedure that helps protect the brain). Blood clots and plaque that severely block the blood flow to the brain is deflected. In the duration of this time, a transcarotid stent is inserted to open and to clear the blockage.

Prior to TCAR, carotid endarterectomy was primarily utilised and widely recognised by many surgeons as the main treatment option. The surgery involves an incision made to open the carotid artery to remove the plaque and concludes with the closure of the repaired artery. However, the incision scars are visible on the neck and the surgery itself may be associated with complications such as bleeding, infection and heart attack. Additional complications associated with cranial nerve injuries can cause issues with swallowing, speaking, and loss of sensation in the face, therefore making carotid endarterectomy disadvantageous. Another surgical procedure that may be recommended is carotid artery angioplasty, which also involves the opening of the blocked carotid arteries. Although this procedure is widely used, there is a possibility that blood clots that can break loose into the bloodstream may form and travel to the  brain although blood thinners may be  given during the procedure to reduce this risk. Besides, a stroke can also occur during this surgical intervention if arterial plaques become dislodged when catheters are being threaded through the blood vessels. The two surgical procedures mentioned above are precisely used for patients suffering from ischemic stroke, where the clot formation only occurs in the brain or elsewhere.

Patients who have suffered from hemorrhagic stroke (occurs due to bleeding in the brain) may undergo neurosurgical procedures including aneurysm clipping, coil embolisation, and arteriovenous malformation (AVM) repair. Although these procedures have been successful in the past, there is still a possibility of a blood clot formation potentially leading to stroke. Another procedure called carotid stenting, involves operating from a typical entry point in the transfemoral (femoral artery in the groin) and through the body and across the blockage in the neck. There is a likelihood that friable vascular disease may get dislodged and travel to the brain, therefore resulting in stroke. Clinical trials prove that transfemoral carotid stenting has a greater risk relative to carotid endarterectomy.

Some surgeons who performed the procedure at Overlook mention the sensitivity of the carotid artery due its proximity to the brain and explain the advantages of this new technology. In their opinion, through significantly reducing stroke, this new procedure allows them to work efficiently within the arteries, ultimately allowing patients to have a better recovery time with less pain. Additionally, Silk Road Medical has also worked with the vascular surgery community to develop the TCAR procedure for over 10 years. Currently, the TCAR procedure also allows doctors to treat more patients; specifically patients aged over 80, suffering from carotid artery disease and who are unable to receive the traditional surgery.

TCAR is considered to be a vital new option to fight stroke and is particularly beneficial for many patients who are at higher risk of complications from carotid endarterectomy due to age, medical conditions, anatomic issues and other risk factors. The surgical procedure using TCAR begins at the neck, rather than the groin, which prevents a  severe risk of stroke associated with transfemoral carotid stenting. After grasping the transcarotid access, temporary blood flow reversal is initiated to rectify and ensure that the brain is sufficiently protected before the stent is placed.

Results from clinical trials of TCAR evoked so much interest among physicians that the Society for Vascular Surgery (SVS), the Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS) recently launched a new program called the TCAR Surveillance Project. Today, TCAR gives hope to many surgeons and perhaps it is a very logical yet ingenious technology that may be a promising innovation for the generations to come.