New Groundbreaking Method for Carotid Disease Patients: Transcarotid Artery Revascularization (TCAR)

Intro: MemorialCare Health System, excellence in healthcare, presents Weekly Dose of Wellness. Here's your host, Deborah Howell.

Deborah Howell (Host): Hello, and welcome to the show. I'm Deborah Howell, and there's some good news for carotid disease patients, and we'll hear about that groundbreaking method today as we talk about transcarotid artery revascularization. Our guest is Dr. Antonio Covarrubias, a vascular surgeon at MemorialCare Orange Coast Medical Center. Welcome, Dr. Covarrubias.

Antonio Covarrubias, MD: Good morning. Thank you for having me.

Deborah Howell (Host): So great to have you on the show today. Let's dive right in, shall we? What is transcarotid artery revascularization, or TCAR?

Antonio Covarrubias, MD: So TCAR is a newer method of treating carotid artery disease. It's a new means of putting a carotid stent into the carotid through the neck. So this is a good procedure to do for patients that had a recent stroke, or in patients that are asymptomatic from carotid disease and are at risk for developing a stroke.

Deborah Howell (Host): And so, who's an ideal candidate for this procedure?

Antonio Covarrubias, MD: The ideal candidates for this are... there are basically two qualifying criteria for this, and it's one that is clinical, and another one that is anatomical criteria. So let's say, for the clinical part, let's say patients that are 75 years of age or older, have had previous heart attacks, CHF, they have uncontrolled diabetes, or they have very bad lung disease, these are great candidates for this type of procedure, given the clinical standpoint. And into the anatomical part, patients that have had previous neck radiation, or they have spinal immobility, they've had restenosis from previous carotid surgeries, or contralateral disease, meaning disease in the other carotid. These are a couple of anatomical features that make patients a great candidate for this.

Deborah Howell (Host): And how is TCAR performed?

Antonio Covarrubias, MD: TCAR, it's performed by a type of hybrid procedure. So it's a small incision at the base of the neck. We get access to the carotid artery, we put in a tube or what we call a sheath, and this sheath is connected to the femoral vein, so a vein in your groin. What this will do is it'll reverse the flow from the carotid down into the femoral vein.

Deborah Howell (Host): And in your opinion, why is this a better procedure for those with high risk for complication?

Antonio Covarrubias, MD: I think this is a better procedure given what I just briefly talked about, is the flow reversal technology. This is a unique technology in which makes the blood flow go from the brain, from the carotid artery, down into the femoral vein. So any type of debris that is broken off when we're doing the procedure won't go up to the brain, and it'll actually go down, it will get caught in a little filter basket that we have, and then the blood will get rerouted back into the femoral vein. So there's basically very minimal blood loss during this procedure. And the reversal of time, usually it's ten minutes or less, so it's very tolerable for the patients. And this is why it makes the stroke rate so low. In the studies that have been done, it's been less than 1%, to be more specific in the latest studies it's been 0.6%. So compared to the standard carotid endarterectomy and the transfemoral carotid artery, this is much lower. So this is great news for carotid artery disease patients.

Deborah Howell (Host): This is... you're kind of blowing my mind. I'm telling you, you're reversing blood flow?

Antonio Covarrubias, MD: Yeah, what it does is, before touching the carotid artery disease, the blood flow is reversed. So for a brief period of time the blood isn't going up to the brain, if not, it's going down towards this filter basket. And again, this is very tolerable, so it's kind of the best of both worlds, meaning the surgery, which is a small incision, and then the hybrid fashion of the endovascular portion is putting in a stent. So you kind of combine both the CEA or the carotid endarterectomy, which has been the traditional for decades, and the transfemoral stenting in one procedure.

Deborah Howell (Host): Wow. Wow, just incredible. What are some of the benefits of TCAR over traditional carotid stenting and carotid endarterectomy surgery?

Antonio Covarrubias, MD: A little bit of what I just said. In carotid endarterectomy, you have to make a larger incision in the neck, you're actually dissecting the whole carotid artery and putting clamps on this. So during this procedure obviously you can break some things off, and the risk of stroke with this procedure has been described as around 2% or 2.3%. And in the transfemoral approach, you actually have to navigate, take a journey through the entire body going from the groin all the way from the aorta and going through the arch and going into the carotid, so you can imagine in taking all this journey through these arteries, you can cause things to break off, and you can actually cause a stroke during this procedure. So that's the major risk that we all worry about with these types of procedures. And with TCAR, you don't have to do that, you go straight to the carotid, and again you don't even touch the disease before having that protection device in place, which is the reversal of flow.

Deborah Howell (Host): And what about the recovery process? How would you describe that, and how quickly can a patient return to their regular activities?

Antonio Covarrubias, MD: I usually tell the patients that the recovery process is instant. Patients that, even after surgery in post-op day one, they're awake, they're in minimal pain. The next day they can have breakfast, they walk, and they leave the hospital. I rarely give any pain medication, meaning opiate pain medication for this. With a little bit of Tylenol or Advil, that's enough for the patients to tolerate the little bit of pain. But they can go straight back to doing their regular activities as soon as they leave the hospital.

Deborah Howell (Host): This is just phenomenal in all regards. How long has TCAR been available to patients?

Antonio Covarrubias, MD: Well, TCAR has been around for a little more than five years, but it's taken a big boom, what I mean by five years is when they started with all the studies and everything. But when I started my fellowship, that this was a little over three years ago, my first procedure in fellowship and training was actually a TCAR. So I was thankfully trained at a great institution down in UCSD, and we were very advanced with the latest technologies. So I've trained significantly in TCAR. And for the last three years we've been doing this fairly regularly on most of our patients that are at high risk for this. And it's again, an amazing technology that I'm glad I'm able to help patients at MemorialCare to do this. We have an excellent team at MemorialCare, all from anesthesia, nursing staff, pre-op and post-op care, even after care when they leave the hospitals. The patients have 24/7 assistance, so it's amazing what we can do and I'm very happy to offer this to all of our patients.

Deborah Howell (Host): Well, that kind of leads to my final question and you spoke to it a little bit already. What support and resources are available after that procedure to a patient and maybe to the patient's family through MemorialCare Heart and Vascular Institute?

Antonio Covarrubias, MD: Yeah, that's sometimes one of the most important things, the family, because and especially at this time with COVID, the patients can't go into the hospital, we want to keep them in the loop. So OCM, where we work at MemorialCare there, has a lot of specialized cardiovascular nurses, NPs, all these trained specialists provide immediate post-op care for this. The patient once they're done with the operation they go to the intensive care unit, they're monitored very closely. Then before they leave, the nurses, the doctors, NPs, we all give extensive education prior to discharge to the patient so they know what the care is. And they have an available line to call 24/7 by cell phone if they have any questions as soon as they leave the hospital.

Deborah Howell (Host): What a happy day for patients. We want to thank you so much, Dr. Covarrubias, for being on our show today. It's been so great talking to you.

Antonio Covarrubias, MD: Thank you. Thank you so much for having me, and have a good day.

Deborah Howell (Host): And for all the good work you do, bravo. To listen to the podcast or for more info, visit memorialcare.org/podcasts. That's memorialcare.org/podcasts. Thanks for listening, and have yourself a fantastic day.