Oregon Health & Science University
  • Cherrie Z. Abraham M.D. Cherrie Z. Abraham M.D.
    Dr. Abraham has advanced training in endovascular operations for complex aortic aneurysms and is one of the most experienced surgeons in the world at endovascular aneurysm repair. Dr. Abraham and Gregory Landry, M.D. performed the first transcarotid artery revascularization (TCAR) in Oregon in February.

New TCAR alternative for restoring artery good news for high risk patients

Watch a short informational video about the TCAR procedure.

Stroke and cranial nerve damage are risks with any carotid artery procedure, but a new method shows improved safety results and may become the best option for patients with increased risk factors.

The first patient in Oregon to receive transcarotid artery revascularization (TCAR) was a 64-year-old female with COPD presenting with restenosis of her carotid endarterectomies on both sides, with her right progressing to severe stenosis in the last two years. Clearly a high risk patient, she benefited from the minimally invasive TCAR technique for carotid artery stenosis.

In February, OHSU vascular surgeons Cherrie Z. Abraham, M.D. and Gregory Landry, M.D. used the TCAR procedure on the patient’s right side. The patient reported that the experience was much easier for her than previous carotid surgeries.

Though it is early to judge whether TCAR will become a standard of care, Dr. Abraham predicts it may potentially replace 25 percent of CEA and 50 percent of CAS procedures.

Comparing CEA, CAS and TCAR

Currently, doctors treating significant carotid artery stenosis perform either surgical CEA (carotid endarterectomy) or endovascular CAS (carotid artery stenting) to repair or replace the diseased artery and restore satisfactory blood flow to the brain.

CEA requires a large incision in the neck, with the attendant risks of cranial nerve injury, hematoma and wound complications. The procedure most often requires general anesthesia for the patient. However, studies suggest that the risk of stroke is slightly lower with CEA than with CAS, making CEA the preferred method for low to moderate risk patients.

Using a transfemoral catheter under a local anesthetic, the increased risk with CAS is associated with dislodging emboli when negotiating the aortic arch and crossing the lesion.

TCAR requires a very small incision into the common carotid artery near the collar bone using local anesthesia. The surgeon clamps the carotid, inserting sheaths to transfer the reverse blood flow to the femoral artery. Along this circuit, there is a filter to trap any emboli from returning to the blood supply.

TCAR advantages and results

  • Preliminary results show TCAR as the safest procedure for stroke risk. Of high surgical risk patients, the incidence of stroke was 1.4 percent within 30 days with TCAR. In the CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) study of CEA in standard surgical risk patients, the incidence of stroke was 2.3 percent within 30 days.
  • TCAR does not require general anesthesia. In fact, the patient is awake and able to converse with the surgeon and take instructions, all signs that neurological function is preserved during the surgery.
  • The amount of ischemia time is much less with TCAR and the procedure is faster.
  • The risk of cranial nerve damage (CNI) is less than with CEA. The CREST study reported a 5.3 percent rate of CNI initially with CEA that reduced to 2.1 percent within six months. Preliminary data from TCAR shows CNI at .7 percent, reducing to 0 percent within six months.
  • Cosmetically, the procedure results in a smaller scar.
  • Typical cases involve an overnight hospitalization, but a return to normal activities within a couple of days.

Status of TCAR at OHSU

The OHSU Knight Cardiovascular Institute is the first institution in Oregon to offer TCAR. All of the results from our TCAR procedures are reported to VQI (Vascular Quality Initiative). At this time, prospective TCAR candidates must be consider at high surgical risk by having a physiological or anatomic issue. The FDA approved the ENROUTE TransCarotid Neuroprotection and Stent System (Silk Road Medical) in April 2016.

When to consult or refer

  • Patients can qualify with either asymptomatic severe carotid artery stenosis or symptomatic moderate to severe carotid artery stenosis.
  • At this time, prospective TCAR patients must have one of the factors listed in the Centers for Medicare and Medicaid Services (CMS) high risk profile.

High risk factors qualifying for TCAR (one or more of the following)

Physiologic Risks
  • Age ≥75
  • Congestive heart failure
  • Left ventricular ejection fraction ≤35%
  • >2 diseased coronaries with ≥70% stenosis
  • Unstable angina
  • Myocardial infarction within six weeks
  • Abnormal stress test
  • Need for open heart surgery
  • Need for major surgery (including vascular)
  • Uncontrolled diabetes
  • Severe pulmonary disease
Anatomic Risks
  • Prior head/neck surgery or irradiation
  • Spinal immobility
  • Restenosis post CEA
  • Surgically inaccessible lesion
  • Laryngeal palsy
  • Laryngectomy
  • Permanent contralateral cranial nerve injury
  • Contralateral occlusion
  • Severe tandem lesions
  • Bilateral stenosis requiring treatment

Contact us

Drs. Abraham and Landry are members at OHSU Knight Cardiovascular Institute and are available to answer questions about TCAR and other clinical programs. For a consultation, please call the OHSU Physician Consult & Referral Service at 503-494-4567. To refer a patient, please fax to 503-346-6854.

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