Advances in care: A better way to treat carotid artery disease

A blockage in your carotid artery in your neck poses the risk of stroke, so removal of the clot is advised. In the past, most carotid artery blockages were removed through an open surgical procedure called a carotid endarterectomy (CEA) or carotid artery stenting.

But a relatively new minimally-invasive procedure called transcarotid artery revascularization (TCAR, pronounced T-car) procedure has been replacing the traditional surgery, especially for patients who are at high risk for open surgery due to other medical conditions or their anatomy. TCAR has been very effective in treating these blockages, said Daniel Gorin, MD, FACS, RVT, a Cape Cod Hospital (CCH) vascular surgeon.

Carotid stents placed through the femoral artery worked, but weren’t as safe as CEA, so it was not widely used, he said. That led to the development of TCAR, which allows for placement of a stent with the safety and effectiveness of traditional surgery.

TCAR originally was approved for patients felt to be high risk for CEA. As more data has been released, it has been found to be safe and effective for all patients and allows a less invasive approach with outcomes as good as traditional surgery.

“The transcarotid artery revascularization procedure is quite a bit faster than the traditional carotid surgery and is pretty straightforward,” said Dr. Gorin, who is chief of vascular surgery at Cape Cod Healthcare.

Data showed that this procedure compared favorably to standard carotid surgery and the risks for a stroke from the procedure were quite low and fell into the 1-2 percent range, essentially similar to standard carotid surgery, he said.

“For most patients, as long as their carotid blockage is of the size and shape that allows us to do the stent, which is 90 percent of patients, it is just as good.”

The CREST Trial

Cape Cod Hospital and Dr. Gorin participated in a clinical trial, called CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) a few years ago to compare outcomes of carotid artery stenting with carotid endarterectomy. The study, published in the New England Journal of Medicine, suggested that “both carotid-artery stenting and carotid endarterectomy are clinically durable and may also reflect advances in medical therapy,” Dr. Gorin said.

The challenge in traditional carotid clot removal was finding a way to place the stent without causing a stroke during the procedure, said Dr. Gorin. That led to the development of TCAR. It solved the problem in two ways:

• Rather than putting the stent in from the groin, where it has to go around a lot of twists and turns, the TCAR stent is placed through a tiny incision in the neck, only a few inches below the blockage.
• During the procedure, blood flow through the carotid artery is reversed, so that any debris that is loosened by the balloon or stent washes out into the filter and doesn’t travel to the brain.

Differences in Procedures

Approximately 160,000 of the 800,000 strokes in the United States annually, are due to carotid artery disease, according to the National Institutes of Health - a figure that aligns with what physicians see at Cape Cod Hospital.

Carotid artery disease occurs when the buildup of plaque (fat, cholesterol, calcium and other substances in the blood) cause blockages in the carotid arteries in your neck.

“These blockages are just below the jawline, are very short - at about one-inch long - and always occur in the same spot,” said Dr. Gorin. “As the artery narrows, the blood doesn’t flow smoothly, and this is where you can get a buildup of a clot. The clot or plaque can break off from the artery wall and flow up to block an artery in the brain, causing an embolic stroke.

“TCAR allows placement of the same type of stent used for transfemoral stenting, but allows us to place it much more safely. TCAR patients have smaller incisions and feel better more quickly than with conventional surgery.”