The role of transcarotid artery revascularization in symptomatic carotid stenosis.

Introduction: Carotid artery stenosis is a significant risk factor for ischemic stroke, particularly in symptomatic patients. While carotid endarterectomy (CEA) has traditionally been the gold standard for management, transcarotid artery revascularization (TCAR) has emerged as a minimally invasive alternative. TCAR combines direct carotid access with flow reversal technology to reduce embolic risk mainly from the aortic arch. This review examines the current evidence regarding the safety, efficacy, and long-term outcomes of TCAR in symptomatic carotid stenosis, comparing it with CEA and transfemoral carotid artery stenting (TFCAS).

Evidence acquisition: PubMed/Medline was searched for studies evaluating the efficacy of TCAR in patients with symptomatic carotid stenosis. Search terms used included 'transcarotid artery revascularization', 'TCAR', 'symptomatic carotid stenosis' and 'stroke' in various combinations.

Evidence synthesis: A total of 187 articles were considered for inclusion in this narrative review. An overview of the TCAR technique, as well as its main advantages and limitations is presented. The clinical evidence from TCAR studies, systematic reviews and meta-analyses is discussed. The indications of TCAR for symptomatic patients are reported based on the recommendations of the 2022 Society for Vascular Surgery guidelines. Finally, patient selection criteria, procedural considerations, and future directions for TCAR in the management of symptomatic carotid disease are analyzed and discussed.

Conclusions: TCAR has demonstrated promising results for the management of both symptomatic and asymptomatic carotid stenosis. The main disadvantage of TCAR is its high cost compared with CEA. Hopefully, the cost-effectiveness of TCAR will improve in the future, thus further increasing its use and applications for the invasive management of patients with symptomatic carotid stenosis.