Introduction
Carotid artery stenosis remains a major cause of ischemic stroke, accounting for significant morbidity and mortality worldwide. Traditionally, carotid endarterectomy (CEA) has been the gold standard for revascularization in symptomatic and selected asymptomatic patients. Says Dr. Michael Lebow, while highly effective, CEA is an open surgical procedure associated with risks such as cranial nerve injury, wound complications, and longer recovery times.
In recent years, minimally invasive approaches have gained traction as safer, less traumatic alternatives. These techniques aim to achieve equivalent stroke prevention outcomes while reducing perioperative morbidity and improving patient recovery. Carotid artery stenting (CAS) and transcarotid artery revascularization (TCAR) are at the forefront of these innovations, supported by an expanding body of clinical evidence.
Carotid Artery Stenting: Current Role
Carotid artery stenting emerged as a less invasive option for patients at high surgical risk due to comorbidities or hostile neck anatomy. The procedure involves endovascular placement of a stent to stabilize the plaque and restore blood flow, usually under local anesthesia. CAS eliminates the need for a neck incision and significantly reduces recovery time compared to open surgery.
However, concerns regarding peri-procedural stroke risk—particularly related to embolization during stent deployment—have limited its widespread adoption. Advances in embolic protection devices, optimized stent designs, and operator experience have significantly improved safety profiles. Current evidence suggests that in carefully selected patients, CAS offers comparable long-term stroke prevention to CEA, particularly when performed in high-volume centers by experienced interventionalists.
Transcarotid Artery Revascularization: A Hybrid Approach
Transcarotid artery revascularization represents the newest development in minimally invasive carotid interventions. TCAR combines the surgical exposure of the common carotid artery with the neuroprotection advantages of flow reversal. By temporarily reversing cerebral blood flow during stent placement, TCAR significantly reduces the risk of embolic stroke, a major limitation of transfemoral CAS.
Clinical trials, such as ROADSTER, have demonstrated exceptionally low stroke rates with TCAR, even in high-risk patients. The hybrid nature of the procedure also makes it feasible in patients with challenging aortic arch anatomy, which can complicate transfemoral access. As evidence accumulates, TCAR is becoming an attractive alternative for both high-risk surgical patients and those with anatomic challenges unsuitable for traditional CAS.
Patient Selection and Future Perspectives
Despite their promise, minimally invasive carotid procedures are not a one-size-fits-all solution. Careful patient selection remains crucial to achieving optimal outcomes. Factors such as lesion location, degree of stenosis, comorbidities, and anatomical considerations guide the decision between CEA, CAS, and TCAR. A multidisciplinary vascular team approach is essential for tailoring treatment strategies to individual patients.
Looking ahead, future directions include refinement of stent technology, development of more effective embolic protection systems, and further integration of imaging and artificial intelligence into procedural planning. Ongoing randomized trials comparing TCAR, CAS, and CEA will help define evidence-based algorithms for patient selection and broaden the understanding of long-term outcomes.
Conclusion
Minimally invasive approaches to carotid revascularization are transforming the landscape of stroke prevention. Carotid artery stenting and transcarotid artery revascularization offer effective alternatives to open surgery, with shorter recovery times and reduced procedural morbidity.
As techniques mature and supporting evidence grows, these approaches are likely to become standard options in comprehensive stroke prevention programs. Future innovations will continue to enhance safety, precision, and patient outcomes, ensuring that carotid revascularization evolves toward less invasive, more individualized care.
