TransCarotid Artery Revascularization (TCAR)
Dr. Yara Gorksi, a vascular and general surgeon, explains TransCarotid Artery Revascularization, or TCAR.
Featured Speaker:
Yara Gorski, MD
Dr. Gorski has been practicing locally since 1999 and holds appointments at Menifee Valley Hospital, Inland Valley Regional Medical Center, Rancho Springs Medical Center, Loma Linda University Medical Center Murrieta, and Temecula Valley Hospital. He is a Fellow of the American College of Surgeons, a Fellow of the American Society of Colon & Rectal Surgeons, and a member of the Southern California Chapter of the American College of Surgeons. Transcription:
TransCarotid Artery Revascularization (TCAR)
Melanie Cole (Host): Welcome to TVH Health Chat with Temecula Valley Hospital. I’m Melanie Cole and I invite you to listen in as we talk today about trans carotid artery revascularization, an amazing new minimally invasive procedure that can help prevent stroke. Joining me is Dr. Yara Gorski. She’s a Vascular Surgeon and a member of the medical staff at Temecula Valley Hospital. Dr. Gorski, welcome to the show. I’m so glad you could join us today. Before we get into this amazing procedure, tell us a little bit about carotid artery disease. What is it? How common is it? And what happens if it’s left untreated?
Yara Gorski, MD (Guest): Hi, good morning. Thank you for having me. It’s a great experience and I’d like to be back to this. And yes, it’s my pleasure to talk about carotid issues. That’s like my bread and butter. It’s something that I’ve been treating since I graduated from my fellowship. Essentially, carotid artery occlusive disease is when you build up plaque in your carotid arteries. The reason to build up plaque in your carotid arteries is the same reason we’ll build up plaque other places in our body. It’s atherosclerosis. It’s when there is hardening of our arteries. And it’s usually related to either high cholesterol, smoking, diabetes, high blood pressure and then certainly there is a genetic component to this. But essentially, those are the risk factors. And once you build up plaque in your carotid artery, a piece of this plaque may dislodge, go to your brain, and cause a stroke.
So, essentially, what we are going to talk here today is how to prevent these strokes that are coming from the plaque build up in the carotid artery.
Host: So, then what was the standard therapy before we’re talking about this procedure TCAR, what had been the main treatment option if someone had severe carotid artery disease and plaques built up and narrowing in there. Tell us what you used to do and what were the risks and complications for this pretty big surgery?
Dr. Gorski: That’s a very good question. What did we do before? Well, carotid artery surgery has been the standard of care for more than 50 years. And essentially, it consists of making an incision on your neck, dissecting the carotid artery, clamping it above and below and removing this plaque. The removal of the plaque is a very delicate procedure. We perform that with special tools where we scoop the plaque out and once, we clean the artery, from the plaque, we have to close this artery with a patch. So, we have to mend a little piece of fabric, special fabric over that opening in the artery. So, this kind of procedure carries a risk for stroke. The risk is less than 3% usually, but it depends on the patient’s population, on the previous history of stroke. This risk can be higher. And other complications that occur with carotid endarterectomy with carotid surgery are related to the surgery itself, just the incision, the cutting of nerves in the neck. So, that has been the traditional procedure. Doing what we call a carotid endarterectomy.
Host: Thank you so much for that description. Dr. Gorski, this is fascinating to me. Tell the listeners what is transcarotid artery revascularization or TCAR as we’re calling it. Tell us a little a little bit about how Temecula Valley Hospital can now treat this type of disease and prevent future strokes because this is really amazing, I want the listeners to hear it.
Dr. Gorski: Yes, yes, yes. Very good. We have been debating like how can we remove this plaque or stop this plaque from going to the brain with a minimally invasive approach. So, all vascular surgeons, most interventionalists, are thinking about this for several years. So, first, we came up with an idea of putting a stent in the carotid. So, stents in the carotid have been done for many years. But in order to deploy the stent in the carotid artery, right there where we have that plaque, traditionally, we go from the groin area. Just like when you get an angiogram for your heart. Most people are familiar with that. They have a catheter that goes either from the groin or from the wrist, catheter goes up to the coronaries and they deploy a stent in there. So, for the carotids, we came up with the same idea. Yeah, we can put a stent and stretch that plaque and make the passage clear so that there will be no longer a risk of stroke. The problem is, when we have to go from the groin area from the femoral artery and navigating inside the aorta all the way to the carotid artery, what we’ve noticed is that it is a very high risk for stroking on the other carotid.
Because remember, both carotids are coming out of your chest area. So, when we go up with wires and catheters, there is a chance of the other side dislodging a little piece. So, stents for carotid artery occlusive disease, has been difficult, very challenging. We still indicate that procedure in some patients for example, if they have irradiation to the neck and we can’t really go in and do surgery, and they need a treatment, we have to take the chance of going through the femoral. So, that’s when TCAR came up. Someone came with a concept of instead of going from the groin, I’m actually going to go right from the neck. So, we make a small incision, just above your clavicle bone, but your collar bone and through that small incision, that’s when we put our wires and catheters and that’s how we deploy the stent. That maneuver instead of going from the groin and going up from your collar bone up has decreased the chances of having a stroke during surgery to almost less than 1.5%. It’s actually less risk of having a stroke than doing open surgery.
So, that is what we started doing at TVH for now almost a year and we are happy to offer this alternative treatment for patients with carotid artery occlusive disease.
Host: Dr. Gorski, this is so interesting, and I’d like you to expand a little bit on the procedure itself. It’s so unique in that blood flow is temporarily reversed during the procedure so that any small bits of plaque that may break off are diverted away from the brain. Tell us a little bit about this part of the procedure that makes it so unique and fascinating.
Dr. Gorski: That’s very nice that you asked that question. Wow, that’s very advanced. And I’ll be happy to explain that. So, during this time, that we’ve been talking about carotid artery occlusive disease, we’ve mentioned how we traditionally would do the surgery, right, remove the plaque through an opening in the neck versus putting a stent in the carotid artery from the groin area. I did not discuss during this time, explaining about those procedures what could potentially happen during surgery or stent with that plaque that’s already there. Because one will think but Dr. Gorski, when you opening in and you are trying to scoop that plaque out, what happens, can the plaque dislodge and cause a stroke during the surgery? Absolutely. That’s one of the main risks that we take when we do this kind of operation.
So, during the time of open surgery, what we do, we clamp the artery. So, we put clamps above and below the area where we are doing the opening to clean up the plaque. So, putting clamps is great, because nothing moves. Whatever we remove out of the area is going to come out and there’s no chance of it causing a stroke. But then, if we are fully clamped, there’s no blood going into the brain. So, during open surgery, what we do, some of us, there are preferences, we put a shunt in the artery. So, there is a technique to do that a specific maneuver where we put a little shunt like a little straw inside the artery, blood keeps flowing and we remove the plaque. Still a risk, a little piece of plaque can be dislodged.
When we go from the groin, we can use a small umbrella with the wires so we navigate through the arteries, we put the wires in the carotid and just above the plaque, we have to pass a small umbrella that will filter any little piece of plaque that could potentially dislodge to the brain. But that is not also perfect. Because even trying to get that umbrella across the plaque is enough to dislodge a little piece and cause a stroke during surgery. So, what TCAR offers that is so unique and so different like you just mentioned, so the idea is if we are operating in the carotid artery, we can reverse the blood flow instead letting the blood go forward, what we do, we clamp the carotid artery and the blood goes back to the femoral vein.
I know it’s a little bit complicated but essentially, it’s doing a short circuit so just before placing the stent, we have a small catheter that we connect to the femoral vein and once we are ready to deploy the stent, right at the neck, we activate this system where aspirate the blood flow from the carotid and sends it to the femoral vein and it recirculates in the body. It’s almost like a little auto-circuit of transfusion. That little maneuver, that process of aspirating the blood while we are manipulating the artery and passing the stent has proven to minimize the risk of a piece of plaque dislodging and going to the brain and causing a stroke and that’s why TCAR is so amazing. We can actually do the same – offer the same benefit of removing the plaque with minimally invasive with a much smaller incision, less risk of having nerve injury from the surgery itself and with less risk of stroke than we would have with open surgery.
Host: That really is absolutely fascinating. Isn’t it cool what you can do now. So, tell patients how soon can they go home and resume normal activities? What is life like for them after this amazing procedure?
Dr. Gorski: That’s a very good question. So, most patients still stay in the hospital overnight, regardless. If we do a stent or if we do a carotid surgery, even if we go from the groin, from the neck TCAR or else, they will spend the night in the hospital and the reason we do that is every time we touch the carotid artery, with either a stent of surgery, there are some changes in your body that are related to the carotid artery per se. So, the carotid arteries have a lot of small nerves attached to it that can affect your blood pressure, your heart rate, so after any procedures in the carotid, you may have either a rapid heart rate or a lower heart rate, your blood pressure may oscillate so due to those changes, potential changes, we wanted to observe those patients for 24 hours. But after that, the go home. So, most patients if they have a procedure like say today at 7:30, I’m doing a TCAR, patient will have the procedure, takes about a couple of hours, sometimes an hour and a half, they stay in the hospital under monitoring and they go home the next day in the morning.
Host: Wow, as we wrap up, Dr. Gorski, is this a game changer do you feel? Has it been well received? Are many vascular surgeons doing it and where do you see the future of procedures such as TCAR going? Tell us a little bit, wrap it up, give us your best advice for listeners about this amazing procedure that you’re doing at Temecula Valley Hospital.
Dr. Gorski: Thank you. Yeah, I totally believe this is a game changer. It’s huge and it came, and it will stay, and it will eventually replace carotid endarterectomy for the majority of patients. We are a team observing, witnessing so many changes in medical care mostly in surgery. Moving from very invasive procedures like I did and like I trained when I was in decades ago, to something minimally invasive available in pretty much every hospital nowadays. So, TCAR is coming to stay. It’s a great option for patients with carotid artery disease that were in the past not considered candidates for surgery. Whether because of their age, or because of their comorbidities or because they have a severe heart problem, today with TCAR we can treat almost everybody that needed a procedure and we should not let people have a stroke because of build up of plaque in the arteries. But ultimately, what I like to leave is a message about health overall.
All that we are talking here is to treat the consequences. We’re discussing how to prevent a stroke from a plaque that has already built up in the patient’s artery. So, I think we need to look back and where it started. Even if you have a genetic background and an increased risk for developing vascular disease say it runs in your family; you still – and that’s how we try to leave patients with this kind of message. It’s still in your hands how are you going to work – how are you going to play your cards, lets put it that way. And we are in charge of how we smoke or not, how we keep a healthy lifestyle, if we do try to exercise and if we eat healthy. And that’s all on us. So, if we work on that, if we prevent that plaque from building up, to begin with, I think we’ll be a lot better. But if you are one of those patients that has it, TVH has what is best out there to offer.
Host: Wow, thank you so much Dr. Gorski. What a fascinating episode. Listeners, please share this episode with friends and family. You got a lot of really good advice and you learned today and that’s what these podcasts are really all about. For more information on how to contact one of the vascular surgeons at TVH, who perform the TCAR procedure, please visit our website at www.temeculavalleyhospital.com. That concludes this episode of TVH Health Chat with Temecula Valley Hospital. Please remember to subscribe, rate and review this podcast and all the other Temecula Valley Hospital podcasts. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. I’m Melanie Cole.
TransCarotid Artery Revascularization (TCAR)
Melanie Cole (Host): Welcome to TVH Health Chat with Temecula Valley Hospital. I’m Melanie Cole and I invite you to listen in as we talk today about trans carotid artery revascularization, an amazing new minimally invasive procedure that can help prevent stroke. Joining me is Dr. Yara Gorski. She’s a Vascular Surgeon and a member of the medical staff at Temecula Valley Hospital. Dr. Gorski, welcome to the show. I’m so glad you could join us today. Before we get into this amazing procedure, tell us a little bit about carotid artery disease. What is it? How common is it? And what happens if it’s left untreated?
Yara Gorski, MD (Guest): Hi, good morning. Thank you for having me. It’s a great experience and I’d like to be back to this. And yes, it’s my pleasure to talk about carotid issues. That’s like my bread and butter. It’s something that I’ve been treating since I graduated from my fellowship. Essentially, carotid artery occlusive disease is when you build up plaque in your carotid arteries. The reason to build up plaque in your carotid arteries is the same reason we’ll build up plaque other places in our body. It’s atherosclerosis. It’s when there is hardening of our arteries. And it’s usually related to either high cholesterol, smoking, diabetes, high blood pressure and then certainly there is a genetic component to this. But essentially, those are the risk factors. And once you build up plaque in your carotid artery, a piece of this plaque may dislodge, go to your brain, and cause a stroke.
So, essentially, what we are going to talk here today is how to prevent these strokes that are coming from the plaque build up in the carotid artery.
Host: So, then what was the standard therapy before we’re talking about this procedure TCAR, what had been the main treatment option if someone had severe carotid artery disease and plaques built up and narrowing in there. Tell us what you used to do and what were the risks and complications for this pretty big surgery?
Dr. Gorski: That’s a very good question. What did we do before? Well, carotid artery surgery has been the standard of care for more than 50 years. And essentially, it consists of making an incision on your neck, dissecting the carotid artery, clamping it above and below and removing this plaque. The removal of the plaque is a very delicate procedure. We perform that with special tools where we scoop the plaque out and once, we clean the artery, from the plaque, we have to close this artery with a patch. So, we have to mend a little piece of fabric, special fabric over that opening in the artery. So, this kind of procedure carries a risk for stroke. The risk is less than 3% usually, but it depends on the patient’s population, on the previous history of stroke. This risk can be higher. And other complications that occur with carotid endarterectomy with carotid surgery are related to the surgery itself, just the incision, the cutting of nerves in the neck. So, that has been the traditional procedure. Doing what we call a carotid endarterectomy.
Host: Thank you so much for that description. Dr. Gorski, this is fascinating to me. Tell the listeners what is transcarotid artery revascularization or TCAR as we’re calling it. Tell us a little a little bit about how Temecula Valley Hospital can now treat this type of disease and prevent future strokes because this is really amazing, I want the listeners to hear it.
Dr. Gorski: Yes, yes, yes. Very good. We have been debating like how can we remove this plaque or stop this plaque from going to the brain with a minimally invasive approach. So, all vascular surgeons, most interventionalists, are thinking about this for several years. So, first, we came up with an idea of putting a stent in the carotid. So, stents in the carotid have been done for many years. But in order to deploy the stent in the carotid artery, right there where we have that plaque, traditionally, we go from the groin area. Just like when you get an angiogram for your heart. Most people are familiar with that. They have a catheter that goes either from the groin or from the wrist, catheter goes up to the coronaries and they deploy a stent in there. So, for the carotids, we came up with the same idea. Yeah, we can put a stent and stretch that plaque and make the passage clear so that there will be no longer a risk of stroke. The problem is, when we have to go from the groin area from the femoral artery and navigating inside the aorta all the way to the carotid artery, what we’ve noticed is that it is a very high risk for stroking on the other carotid.
Because remember, both carotids are coming out of your chest area. So, when we go up with wires and catheters, there is a chance of the other side dislodging a little piece. So, stents for carotid artery occlusive disease, has been difficult, very challenging. We still indicate that procedure in some patients for example, if they have irradiation to the neck and we can’t really go in and do surgery, and they need a treatment, we have to take the chance of going through the femoral. So, that’s when TCAR came up. Someone came with a concept of instead of going from the groin, I’m actually going to go right from the neck. So, we make a small incision, just above your clavicle bone, but your collar bone and through that small incision, that’s when we put our wires and catheters and that’s how we deploy the stent. That maneuver instead of going from the groin and going up from your collar bone up has decreased the chances of having a stroke during surgery to almost less than 1.5%. It’s actually less risk of having a stroke than doing open surgery.
So, that is what we started doing at TVH for now almost a year and we are happy to offer this alternative treatment for patients with carotid artery occlusive disease.
Host: Dr. Gorski, this is so interesting, and I’d like you to expand a little bit on the procedure itself. It’s so unique in that blood flow is temporarily reversed during the procedure so that any small bits of plaque that may break off are diverted away from the brain. Tell us a little bit about this part of the procedure that makes it so unique and fascinating.
Dr. Gorski: That’s very nice that you asked that question. Wow, that’s very advanced. And I’ll be happy to explain that. So, during this time, that we’ve been talking about carotid artery occlusive disease, we’ve mentioned how we traditionally would do the surgery, right, remove the plaque through an opening in the neck versus putting a stent in the carotid artery from the groin area. I did not discuss during this time, explaining about those procedures what could potentially happen during surgery or stent with that plaque that’s already there. Because one will think but Dr. Gorski, when you opening in and you are trying to scoop that plaque out, what happens, can the plaque dislodge and cause a stroke during the surgery? Absolutely. That’s one of the main risks that we take when we do this kind of operation.
So, during the time of open surgery, what we do, we clamp the artery. So, we put clamps above and below the area where we are doing the opening to clean up the plaque. So, putting clamps is great, because nothing moves. Whatever we remove out of the area is going to come out and there’s no chance of it causing a stroke. But then, if we are fully clamped, there’s no blood going into the brain. So, during open surgery, what we do, some of us, there are preferences, we put a shunt in the artery. So, there is a technique to do that a specific maneuver where we put a little shunt like a little straw inside the artery, blood keeps flowing and we remove the plaque. Still a risk, a little piece of plaque can be dislodged.
When we go from the groin, we can use a small umbrella with the wires so we navigate through the arteries, we put the wires in the carotid and just above the plaque, we have to pass a small umbrella that will filter any little piece of plaque that could potentially dislodge to the brain. But that is not also perfect. Because even trying to get that umbrella across the plaque is enough to dislodge a little piece and cause a stroke during surgery. So, what TCAR offers that is so unique and so different like you just mentioned, so the idea is if we are operating in the carotid artery, we can reverse the blood flow instead letting the blood go forward, what we do, we clamp the carotid artery and the blood goes back to the femoral vein.
I know it’s a little bit complicated but essentially, it’s doing a short circuit so just before placing the stent, we have a small catheter that we connect to the femoral vein and once we are ready to deploy the stent, right at the neck, we activate this system where aspirate the blood flow from the carotid and sends it to the femoral vein and it recirculates in the body. It’s almost like a little auto-circuit of transfusion. That little maneuver, that process of aspirating the blood while we are manipulating the artery and passing the stent has proven to minimize the risk of a piece of plaque dislodging and going to the brain and causing a stroke and that’s why TCAR is so amazing. We can actually do the same – offer the same benefit of removing the plaque with minimally invasive with a much smaller incision, less risk of having nerve injury from the surgery itself and with less risk of stroke than we would have with open surgery.
Host: That really is absolutely fascinating. Isn’t it cool what you can do now. So, tell patients how soon can they go home and resume normal activities? What is life like for them after this amazing procedure?
Dr. Gorski: That’s a very good question. So, most patients still stay in the hospital overnight, regardless. If we do a stent or if we do a carotid surgery, even if we go from the groin, from the neck TCAR or else, they will spend the night in the hospital and the reason we do that is every time we touch the carotid artery, with either a stent of surgery, there are some changes in your body that are related to the carotid artery per se. So, the carotid arteries have a lot of small nerves attached to it that can affect your blood pressure, your heart rate, so after any procedures in the carotid, you may have either a rapid heart rate or a lower heart rate, your blood pressure may oscillate so due to those changes, potential changes, we wanted to observe those patients for 24 hours. But after that, the go home. So, most patients if they have a procedure like say today at 7:30, I’m doing a TCAR, patient will have the procedure, takes about a couple of hours, sometimes an hour and a half, they stay in the hospital under monitoring and they go home the next day in the morning.
Host: Wow, as we wrap up, Dr. Gorski, is this a game changer do you feel? Has it been well received? Are many vascular surgeons doing it and where do you see the future of procedures such as TCAR going? Tell us a little bit, wrap it up, give us your best advice for listeners about this amazing procedure that you’re doing at Temecula Valley Hospital.
Dr. Gorski: Thank you. Yeah, I totally believe this is a game changer. It’s huge and it came, and it will stay, and it will eventually replace carotid endarterectomy for the majority of patients. We are a team observing, witnessing so many changes in medical care mostly in surgery. Moving from very invasive procedures like I did and like I trained when I was in decades ago, to something minimally invasive available in pretty much every hospital nowadays. So, TCAR is coming to stay. It’s a great option for patients with carotid artery disease that were in the past not considered candidates for surgery. Whether because of their age, or because of their comorbidities or because they have a severe heart problem, today with TCAR we can treat almost everybody that needed a procedure and we should not let people have a stroke because of build up of plaque in the arteries. But ultimately, what I like to leave is a message about health overall.
All that we are talking here is to treat the consequences. We’re discussing how to prevent a stroke from a plaque that has already built up in the patient’s artery. So, I think we need to look back and where it started. Even if you have a genetic background and an increased risk for developing vascular disease say it runs in your family; you still – and that’s how we try to leave patients with this kind of message. It’s still in your hands how are you going to work – how are you going to play your cards, lets put it that way. And we are in charge of how we smoke or not, how we keep a healthy lifestyle, if we do try to exercise and if we eat healthy. And that’s all on us. So, if we work on that, if we prevent that plaque from building up, to begin with, I think we’ll be a lot better. But if you are one of those patients that has it, TVH has what is best out there to offer.
Host: Wow, thank you so much Dr. Gorski. What a fascinating episode. Listeners, please share this episode with friends and family. You got a lot of really good advice and you learned today and that’s what these podcasts are really all about. For more information on how to contact one of the vascular surgeons at TVH, who perform the TCAR procedure, please visit our website at www.temeculavalleyhospital.com. That concludes this episode of TVH Health Chat with Temecula Valley Hospital. Please remember to subscribe, rate and review this podcast and all the other Temecula Valley Hospital podcasts. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. I’m Melanie Cole.