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New 'TCAR' procedure decreases stroke risk during carotid surgery

Posted on Nov. 7, 2017 ( comments)
By reversing the flow of blood, debris is carried away from the brain and into a filter where it is removed from the body. (Graphic courtesy of Silk Road Medical)

Surgeons at MultiCare Health System’s Pulse Heart Institute are performing an innovative new procedure that reduces the risk of stroke while clearing blockages in patients’ carotid arteries while also providing a faster recovery time than traditionally prevalent methods.

TransCarotid Artery Revascularization, known as TCAR, reverses the flow of blood through the brain to send plaque dislodged during the procedure away from the brain and into an external filter where it is captured, significantly reducing the risk of stroke.

Vascular surgeons Chatt Johnson, MD, and Nick Garcia, MD, began performing the TCAR procedure at Good Samaritan Hospital in August.  

“One of the innovations is that we are actually reversing the flow,” Johnson says. “So instead of the plaque breaking off, it’s coming out of the body.”

Currently, the Carotid Endarterectomy procedure is the most common way to remove plaque from the carotid artery, accounting for about 90 percent of procedures nationwide. It requires a 5-6 cm incision on the neck to open the carotid artery to remove plaque. The typical hospital stay is 1-2 days, depending on a patient’s condition. 

Another well-known option is angioplasty and stent placement via the femoral artery. This procedure places a catheter in the groin, which is moved through the artery to the blockage. A smaller catheter with a very small balloon is placed through the first catheter, then inflated to open the artery. Stents may also be placed to keep the artery open. The drawback of this procedure is the danger of plaque breaking loose and flowing into the brain, increasing the chance of stroke. 

“The biggest problem is there is a risk of stroke when you are doing a procedure: this new procedure has the lowest stroke risk of any of those interventions,” Johnson says. “We wanted to bring that to the community.”

With TCAR, a 1-2 cm incision is made above the collarbone to access the carotid artery. A sheath is placed directly into the artery and connected to a system that reverses the flow of blood away from the brain. The balloon angioplasty and stenting are performed while blood flow is reversed, with the blood traveling through the filter outside of the body that removes any plaque before returning it through a vein in the patient’s thigh. Once complete, blood flow is returned to its normal direction.

“The incision is probably 1/3 the size of the other procedure’s incision, and because of that the recovery is faster,” Garcia adds. It is also less time consuming than the carotid endarterectomy, taking 45 minutes to 1.5 hours. Patients leave the hospital the next day.

A trial with high-risk patients indicated a 1.4 percent stroke risk following TCAR, compared to a 2.3 percent risk following a carotid endarterectomy. The transfemoral stent presents a 4.1 percent stroke risk, which climbs to 6.9 percent in patients over the age of 75.

As they prepared to implement TCAR, the surgeons focused on creating consistent processes for all members of the care team to ensure consistent performance every time.

“Everyone on the team knows what the next step is, and it’s a better process for the patient,” Johnson says. “Every step has been standardized.”

TCAR was federally approved in 2016, although it has been in various forms of testing for around eight years. MultiCare is the second organization in the state to offer the procedure.

Patients must meet several qualifications for TCAR, based on age, risk factors and anatomical criteria. These are best discussed on an individual basis with a cardiac provider.


Learn more about TCAR

Learn more about Pulse Heart Institute

Find a Pulse Heart Institute Provider


About The Author

Mark Swart

Mark Swart joined MultiCare Health System after retiring from Army Public Affairs at Joint Base Lewis McChord, Wa. He has extensive storytelling and communications experience from operations around the globe. Mark enjoys being active outdoors, whether it is running, sailing, motorcycling or even working in his yard.

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