Contributed by Steve Henao, MD
A very pleasant, active 75-year-old patient at our hospital received the disturbing news last July that she had an 80 percent blockage in one of her two carotid arteries, a diagnosis known as carotid artery disease. She was concerned about the risk of treatment and overwhelmed by the confusing information available on the internet regarding her condition and options for care, asking “should I have regular surgery or should I have a stent?” What follows is a brief summary of the information I shared with her during her appointment, where we discussed the contemporary, evidence-based treatment options for carotid disease.
Disease of one or both of the arteries that provide blood to the brain is responsible for up to one-third of strokes if blood flow stops or plaque fragments dislodge and travel to the brain. Carotid disease is one of the most preventable and easy-to-treat causes of stroke. If not severe, carotid disease can be treated medically with antiplatelet drugs or statins, but for patients with >80 percent carotid stenosis, the “gold standard” surgical treatment of carotid endarterectomy (CEA) is indicated. CEA has been around for decades, longer than any other modality. It’s an open surgical procedure, in which surgeons cut open the artery and remove the plaque causing the blockage. CEA is recognized as a safe, effective surgery, with a lot of data behind it. But patients 75 and older are considered high-risk for CEA because the artery is clamped shut for up to 45 minutes. During this time, the patient relies entirely on blood delivered by the other carotid artery. To maintain blood flow, surgeons have to increase the patient’s heart rate and blood pressure to force blood from one hemisphere of the brain to the other. This puts additional stress on the patient’s heart. As a result, CEA could actually cause a stroke or heart attack on the operating table in high-risk patients, despite its aim to prevent future strokes. Recent evidence suggests that there may be a safer alternative at her age. At our center, we draw a line in the sand at age 75 given the high risk for potential perioperative complications and consider alternative therapies.
The traditional alternative to CEA has been to place a stent into the carotid artery originating from the leg, or trans-femoral carotid stenting. This is a less invasive option that requires manipulating a wire and catheter system through the body into the chest, where the devices are ultimately placed into the neck. This is currently approved only for patients that are considered high risk and have symptoms. Unfortunately, this procedure has been shown to cause a significantly higher number of strokes compared to traditional surgery.
Fortunately, the Food and Drug Administration recently approved another option for a less invasive stenting procedure for use in high risk surgical patients, and it represents the modernization of carotid repair. Called Transcarotid Artery Revascularization, or TCAR, it is intended to lower the risk of stroke or heart attacks during and after the procedure in high risk patients. With TCAR, we can limit the stress on the heart, and keep the procedure as safe and effective as the conventional CEA approach.
Like CEA, the TCAR procedure involves direct access to the carotid artery, but through a much smaller incision at the neckline just above the clavicle instead of a longer incision down the neck. What’s unique about TCAR is it reverses blood flow away from the brain to protect against fragments of plaque that may come loose during the procedure. After a stent is placed in the carotid artery, blood is filtered before flow reversal is turned off and flow to the brain resumes in its normal direction. The entire procedure is performed in less than half the time of CEA – limiting the stress on the heart and significantly cutting the risk of the patient having a stroke or heart attack during the procedure. The procedure offers several other advantages as well: Local anesthesia is favored, and hospital stays are typically overnight for observation. TCAR patients recover quickly and almost always go home the next day with less pain and smaller scars.
TCAR has been studied extensively, and the clinical data have been excellent. A study that led to FDA approval for the TCAR procedure found that TCAR cut the risk of a stroke or heart attack to 1.4 percent, compared with a of 2.3 percent for CEA. Interim results of a real-world study presented last November at the VEITHSymposium showed a trend for an even lower stroke rate of 1.1 percent. While a 1 percent reduction in stroke risk may not sound like much, it translates to approximately one less patient out of 100 having to live with the potentially devastating effects of stroke.
Whereas before we would have had few options for high risk patients in the past, we were able to perform TCAR on this patient. She experienced an over-night stay in the hospital and was able to go home within 24 hours of her surgery with a small, one-inch incision over her collar bone that allowed for a very uneventful recovery at home and a rapid return to her regular lifestyle within 2 to 3 weeks. While carotid endarterectomy is still considered the gold standard for carotid disease, we now perform TCAR regularly on symptomatic and asymptomatic patients at high risk for surgery – providing a treatment option to many who previously had few options.
May is recognized as American Stroke Month – a time when health care providers across the country join together to help save lives through patient education and sharing best practices in preventing and treating stroke. Let’s continue to educate our patients, peers and community about ways to prevent stroke – but let’s also make sure we stay at the forefront of technology and innovation to help improve stroke outcomes and save lives.
Dr. Steve Henao is medical director of cardiovascular research at the New Mexico Heart Institute.
 Kwolek CJ, et al. Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal. J Vasc Surg. 2015;62:1227-35. http://www.jvascsurg.org/article/S0741-5214(15)01147-7/pdf