New Direction in Treatment for Blocked Carotid Arteries

The concept of reversing the direction of your blood flow, even temporarily, may seem astounding, but that’s exactly what’s at the center of an ingenious treatment being used increasingly to prevent strokes.

The procedure, called transcarotid artery revascularization, or TCAR, employs special equipment to divert blood flow in the opposite direction while physicians treat clogged carotid arteries that carry blood to the brain. This minimally invasive procedure has become an important choice for patients who need such intervention.

Aidan Hamm, M.D., vascular and general surgeon at Baptist Health Bethesda Hospital East and Bethesda Hospital West

“If we can get in there and treat them — particularly with the minimally invasive option, the TCAR — then we can really improve people’s lives,” says vascular and general surgeon Aidan Hamm, M.D., a member of the fellowship-trained team of vascular surgeons at Baptist Health Bethesda Hospital East and Bethesda Hospital West. “By treating this condition, we can help prevent patients from having life-altering complications, like strokes.”

Previously, this relatively new endovascular approach was reserved by the FDA for only a small subset of patients. However, several years of data has shown that it is as safe and successful as the more traditional endarterectomy “open surgery,” while also offering the benefits of a quicker recovery, smaller incision and reduced risk of nerve injury.

“The TCAR procedure involves direct access to the carotid artery, but through a much smaller incision at the neckline just above the clavicle, instead of a longer incision on the neck that occurs during traditional open surgery,” explains vascular and general surgeon Rennier Martinez, M.D., who also is based at Bethesda. “The entire procedure is performed in less than half the time of traditional open surgery, which limits the stress on the heart and reduces anesthetic effects. This aids in the management of complicated patients with difficult anatomy.”

When Is Treatment Needed?

The carotid arteries are vital blood vessels in the neck that deliver oxygen-rich blood to the brain. Carotid artery disease occurs when these blood vessels become clogged with fatty material called plaque. When plaque builds up, it impedes blood flow, known as carotid artery stenosis.

Rennier Martinez, M.D., vascular and general surgeon at Baptist Health Bethesda Hospital East and Bethesda Hospital West

Carotid artery disease is estimated to be the source of stroke in up to a third of cases, with more than 400,000 new diagnoses of the disease each year in the United States alone, according to the Centers for Disease Control and Prevention.

Carotid arteries that are clogged with plaque are stiff and narrow and have trouble delivering oxygen and nutrients to vital brain structures. Also, a piece of plaque or blood clot may break off and travel to smaller arteries in the brain, cutting off blood supply. A lack of oxygen may cause permanent damage to the brain, or death.

As a person ages, the risk of developing carotid artery stenosis increases. Other risk factors for carotid artery disease include diabetes, a family history of stroke, high blood pressure, high cholesterol and obesity.

“Your risk is something you should definitely discuss with your physician,” Dr. Hamm notes. “People with known coronary artery disease, for example, should routinely get screened for their carotid arteries, because if you have buildup of plaque and atherosclerosis in the heart, you may have it elsewhere, as well.”

What to Look For

Carotid artery disease is usually diagnosed by imaging such ultrasound. Your physician may use a stethoscope to listen over your carotid artery for a swooshing sound, known as bruit, which is caused by a blockage.

Some symptoms of carotid artery disease include blurred vision or vision loss, numbness or weakness one side, dizziness and loss of balance, and problems with thinking, reasoning, memory and speech. More often than not, however, carotid disease is asymptomatic until a stroke occurs. “This is what makes it so worrisome and important to diagnose before it become symptomatic,” Dr. Martinez says.

Left untreated, carotid artery disease will worsen, Dr. Martinez says.

If blood flow is only slightly restricted, patients are often treated with medications to control contributing factors like high cholesterol or high blood pressure. But if the blockage is severe, surgery to remove the plaque and stenting are recommended, Dr. Martinez explains.

Understanding Treatment Options

For many years, the standard treatment option for advanced carotid artery disease was carotid endarterectomy, an open surgical procedure that involves a large incision on the neck and an associated risk of cranial nerve injury that can result in difficulty with swallowing, speaking and sensation in the face.

With TCAR, the risks of complications are reduced. A tube is inserted into the carotid artery and is connected to a system that temporarily directs blood flow away from the brain to protect against dangerous debris reaching the brain during the procedure, which could cause a stroke.

During the procedure, that blood is filtered through a device outside of the body and then safely returned through a blood vessel in the leg. During this “reverse flow,” blood still reaches the brain through other blood vessels. When the procedure is complete, normal blood flow in the correct direction is restored.

With its ingenious flow-reversal system, TCAR eliminates the need to navigate catheters from the groin through the heart’s aortic arch, which increases the risk of stroke during the procedure. TCAR has been shown to result in fewer stroke complications compared to traditional transfemoral catheter-based carotid stenting.

The technique may not be right for every patient, but with expanded approval by the FDA, National Institutes of Health statistics show more patients are choosing TCAR when it is an option. The TCAR procedure also is offered at Miami Cardiac & Vascular Institute, part of Baptist Health.

TCAR opens up a good option for many people, says Dr. Martinez. He likes to work with patients to develop goals that allow them to manage their conditions and return to the things they enjoy.

“The future of vascular surgery lies in highly innovative technological advances that allow us to treat complex conditions that before, might not have been treated, or would have been treated differently,” Dr. Martinez says. “Being trained in up-and-coming technology in vascular surgery allows the surgeon to provide better care and a more expedited recovery.”