TCAR was in the news at the February 2022 International Stroke Conference. The acronym is short for “transcarotid artery revascularization” stenting. Less than a year ago the Society for Vascular Surgery published online recommendations for the treatment of extracranial carotid disease noting that “TCAR is superior or preferable to TF-CAS [transfemoral carotid artery stenting] or CEA [carotid endarterectomy] for patients with high anatomic and/or physiologic surgical risk.” TCAR advocates are trying to establish a role for it in the treatment of patients with symptomatic carotid occlusions.
Dr. Gert J. de Borst in a Dec 2021 Stroke commentary, Transcarotid Artery Stenting: Hype or Hope?” states, “There is no doubt that carotid stenting has evolved considerably during the last 2 decades, but for now, CEA remains safer than stenting for most patients in all periods after the onset of symptoms. So how can TCAR establish a generalizable and safe role in a real-world setting? At all times, as a prophylactic procedure, carotid
revascularization should occur early after index symptoms to prevent as many strokes as possible. Although the current evidence is promising, independent, and preferentially investigator-driven, well-designed, randomized controlled studies comparing TCAR with CEA in recently symptomatic patients are necessary. [https://lnkd.in/dq9XWQXY]
[T]here are several elephants in the room that need to be discussed before TCAR can fulfill a more generalizable role.
· No RCT has compared TCAR with either CEA or TFCAS
(and this was disregarded in most of the published reviews).
· The quality of the studies is very modest. The Methodological Index for Non-Randomized Studies score classified studies (6/18) as moderate or poor quality (12/18).
· Most of the registry cohorts to evaluate TCAR were dominated by the inclusion of asymptomatic patients.
· Proper comparison of TCAR versus CEA in symptomatic patients only has thus far not been performed.
· Most data were derived from company-sponsored single-arm studies or comparative analyses with historical controls.
· Three-quarters of the patients of all available data originate from the Vascular Quality Initiative registry limiting the generalizability of outcome.
· Data on compliance with the instructions for use are mostly lacking.
· Anatomic suitability and exclusion criteria for TCAR have been underreported. One-fourth of patients may be unsuitable for TCAR because of anatomic restrictions such as a short neck or flow reversal intolerance.
· In TFCAS, the pathophysiological mechanism of 30-day stroke (1/3 of the cohort) was hemodynamic. While TCAR may reduce the risk of embolic stroke, it cannot diminish the risk of hemodynamic stroke.
· Preference and cost-effectiveness would come into play once noninferiority of TCAR relative to CEA could be proven.”
Will TCAR rollout upend CREST-2 trial enrollment in 2022?