A new type of surgery carries less risk when clearing plaque from the cartoid arteries.
A groundbreaking new treatment is now available to help some patients with carotid artery disease, a leading cause of stroke. TransCarotid Artery Revascularization (TCAR) has fewer risks than other options, reduces scarring and gets patients out of the hospital and back on their feet sooner.
“TCAR is specifically designed to treat high-risk patients with carotid artery disease in the safest way possible,” says Daniel Fremed, MD, a board-certified vascular surgeon at Clara Maass Medical Center (CMMC). About a third of all strokes are caused by carotid artery disease. Fatty deposits (known as plaque) clog arteries and reduce or block blood flow to the brain. “Strokes can be life-altering and debilitating,” says Dr. Fremed. “Stroke survivors can be left physically and cognitively impaired.” The TCAR procedure is a new way to prevent strokes from occurring.
Traditional treatments
The most common treatment for carotid artery disease is carotid endarterectomy (CEA). To do this, a surgeon makes an incision on the patient’s neck. Then the surgeon opens the carotid artery and removes the plaque. Another option, called angioplasty, inflates a tiny balloon in the artery to open it up. A surgeon may also put a stent (a tiny tube) in the artery to keep it open. To reach the carotid artery, the surgeon must feed a catheter up to the neck from a puncture in the femoral artery in the groin.
These two treatments carry certain risks. CEA is open surgery, which requires a large incision. It is commonly performed under general anesthesia and carries a risk of nerve injury. With angioplasty, the danger is that pieces of plaque could break loose and move into the brain. That in itself can cause a stroke.
For some patients, including those with diabetes and heart or lung disease, surgery already carries greater risks. For these patients in particular, TCAR is a great benefit. “TCAR eliminates the riskiest parts of traditional carotid surgery and stenting and delivers an extraordinarily safe procedure, especially for high-risk patients,” says Dr. Fremed.
How TCAR works
TCAR helps reduce risk in two ways. First, it requires a smaller cut, less than an inch long, just above the collarbone, rather than up to several inches along the length of the neck, as CEA does. “This smaller incision can lead to less postoperative pain and a quicker recovery,” Dr. Fremed explains. Through this minimally invasive opening, surgeons can reach the carotid artery and insert a slender tube. Then they put a stent inside the artery to open it up so blood flows freely to the brain.
The other key factor with TCAR is that, incredibly, it temporarily reverses the blood flow to the brain. Surgeons clamp the carotid artery feeding blood to the brain. Then they redirect the blood back from the brain through a tube leading to a vein in the thigh. During the procedure, blood flowing away from the brain goes through a filter before it reenters the body. In this way, if pieces of plaque break off, they won’t get to the brain and cause a stroke, as is the risk with more traditional interventions for carotid artery disease. This reversal of blood flow takes about 10 minutes and doesn’t harm the brain because other arteries continue to supply blood to the brain during this time.
Home sooner
Along with greatly reduced risk of stroke and nerve damage, patients recover faster and with less scarring. Often, they are able to return home and get back to their normal activities the next day. “Most patients undergoing TCAR can be discharged on post-op day one,” Dr. Fremed says. “It is an overnight hospital stay to monitor their blood pressure and the incision.”
Surgeons at CMMC have been performing TCAR for about a year. “There are only a handful of hospitals in New Jersey performing this procedure,” says Dr. Fremed. In the future, other hospitals seem certain to follow this lead. Dr. Fremed says that TCAR is so safe that it may even eventually be used with low-risk patients. Says Dr. Fremed, “TCAR turns treating high-risk carotid artery disease into a very safe procedure.”
What is cartoid artery disease?
What it is: A waxy substance called plaque builds up in one or both of the carotid arteries, the vessels in the neck that carry oxygen-rich blood to the brain. Blood flow to the brain may be interrupted, causing a stroke.
What causes it: Factors that damage the inner layers of the carotid arteries, such as smoking, high levels of cholesterol, high blood pressure and high levels of sugar in the blood.
Treatment: Lifestyle changes, such as heart-healthy eating, maintaining a healthy weight and being as physically active as you can reduce the risk. If those measures aren’t enough, your doctor may prescribe medicines to help control risk factors.
Warning signs: For some people a “mini-stroke”—a transient ischemic attack, or TIA—is a warning sign. Symptoms include sudden trouble seeing or speaking, dizziness, a severe sudden headache or sudden weakness in the face or limbs—similar to symptoms of an actual stroke, although these usually go away within 24 hours. If you or a loved one have these symptoms, call 911 as soon as possible.
For a referral to a Clara Maass Medical Center vascular surgeon, call 888.724.7123.