TCAR, or transcarotid artery revascularization, is a minimally invasive procedure that opens a narrowed carotid artery in your neck to reduce your risk of stroke. It combines a small surgical incision with stent placement, and its defining feature is a built-in system that temporarily reverses blood flow away from your brain during the procedure. This keeps any debris dislodged during stenting from reaching the brain, where it could cause a stroke. First performed in 2004 and approved by the FDA in 2015, TCAR has become a widely used alternative to both traditional open surgery and stenting done through the groin.
Why Carotid Artery Narrowing Matters
Your two carotid arteries run up either side of your neck and supply blood to your brain. When fatty plaque builds up inside one of these arteries, the condition is called carotid stenosis. The danger isn’t just reduced blood flow. Pieces of that plaque can break loose, travel to the brain, and block smaller vessels, causing a stroke. Treating significant carotid narrowing before that happens is the entire goal of procedures like TCAR.
How TCAR Works
The procedure starts with a small incision, typically 2 to 3 centimeters, low on the side of your neck just above the collarbone. Through this opening, the surgeon accesses the common carotid artery directly. This is a key distinction from traditional stenting done through the groin (called transfemoral stenting), which requires threading wires and catheters up through the body’s largest artery, the aorta, and around the aortic arch to reach the neck. That journey through the aorta carries its own stroke risk, since the catheter can dislodge plaque along the way. TCAR skips it entirely.
Once the artery is accessed, the surgeon connects the ENROUTE Neuroprotection System. This device temporarily reverses the direction of blood flow at the treatment site, pulling blood away from the brain rather than toward it. The diverted blood passes through an external filter that catches any loose particles, then returns the cleaned blood to a vein in your leg. With this protection in place, the surgeon advances a balloon to widen the narrowed section and deploys a small self-expanding mesh stent made of a nickel-titanium alloy called nitinol. The stent locks into place against the artery wall, holding it open permanently. After the stent is positioned, flow reversal is turned off and normal blood flow resumes.
Who Is a Candidate
TCAR was originally developed for patients considered high risk for traditional open surgery (carotid endarterectomy) but who also have anatomy that makes groin-based stenting dangerous. Specific anatomical features that can make the groin approach hazardous include a steep or complex aortic arch, heavy calcification or loose plaque in the aorta, significant narrowing where the carotid artery branches off the aorta, or severe twisting of the internal carotid artery higher in the neck.
Not everyone is eligible for TCAR either. The artery needs to be a certain size (the internal carotid artery between 4 and 9 millimeters in diameter, the common carotid artery greater than 6 millimeters), and there must be enough distance, at least 5 centimeters, between the collarbone and the point where the carotid artery splits. About 75% of patients meet that distance requirement. The access site on the lower carotid artery also needs to be relatively free of plaque itself. More recently, TCAR has been studied in standard-risk patients as well, not just those at high surgical risk.
Safety and Stroke Prevention Results
The most recent large prospective trial, called ROADSTER 3, enrolled 344 patients and reported a combined stroke, death, and heart attack rate of just 0.9% within 30 days. There were three strokes and zero deaths or heart attacks in the entire study population. Those numbers are notably low for any carotid intervention.
Compared to traditional open surgery (carotid endarterectomy, or CEA), TCAR shows similar short-term results. In a large single-center study of over 600 procedures, the 30-day stroke rate was 2% for TCAR and 1% for CEA, a difference that was not statistically significant. However, at two years of follow-up, open surgery showed an advantage: the combined stroke and death rate was 8% for CEA patients compared to 15% for TCAR patients. The rate of significant re-narrowing of the artery also trended lower with open surgery, though that gap did not reach statistical significance. These longer-term findings suggest that while TCAR performs well in the short run, open surgery may still have an edge for patients who can safely undergo it.
Potential Complications
Like any vascular procedure, TCAR carries risks. The most serious is stroke, though the flow reversal system is specifically designed to minimize this. Bleeding at the incision site is another concern. Patients who develop bleeding complications are more likely to experience a cascade of other problems, including cranial nerve injury (which can temporarily affect swallowing or voice), heart rhythm disturbances, wound infection, and in rare cases heart attack or heart failure flare-ups.
Cranial nerve injury is less common with TCAR than with traditional open surgery, largely because the incision is smaller and lower on the neck, away from the nerves that run near the upper carotid artery. When nerve issues do occur, they are usually temporary.
Recovery and What to Expect
TCAR is performed under general anesthesia or, in some cases, regional anesthesia with sedation. The procedure itself typically takes less time than open carotid surgery. Most people go home the day after the procedure. You should plan to take it easy for at least a week before returning to your normal activities. The neck incision is small enough that it heals quickly, and you will likely be started on blood-thinning medication to help keep the new stent open. Follow-up imaging, usually an ultrasound of the neck, is scheduled in the weeks and months afterward to confirm the stent is functioning well and the artery remains open.
TCAR vs. Open Surgery vs. Groin-Based Stenting
- Open surgery (CEA): A larger neck incision is used to physically remove plaque from the artery. It has the longest track record and the best long-term durability data. The tradeoff is a higher risk of cranial nerve injury and a longer recovery, and it requires the patient to tolerate a more invasive operation.
- Groin-based stenting (transfemoral CAS): A catheter is threaded from the femoral artery in the groin up through the aorta to the neck. No neck incision is needed, but crossing the aortic arch introduces stroke risk from dislodging plaque along the way. This approach is less ideal for patients with complex aortic anatomy.
- TCAR: Combines the direct neck access of surgery with the stent placement of an endovascular approach, while adding flow reversal for brain protection. The incision is smaller than CEA, and it avoids the aortic arch entirely. It fills a niche for patients whose anatomy makes groin-based stenting risky or who face elevated surgical risk from open repair.
The choice between these three approaches depends on your specific anatomy, your overall health, and the severity and location of the plaque. In many cases, TCAR offers a middle ground: less invasive than open surgery, with stronger brain protection than stenting from the groin.