From medical therapy to conventional surgery to carotid angioplasty and stenting, the Johns Hopkins Heart and Vascular Institute offers comprehensive treatment options for carotid artery disease, says Bruce Perler, vice chair for clinical operations and financial affairs, and chief emeritus of the Division of Vascular Surgery and Endovascular Therapy. Within the last year, the institute also added the latest minimally invasive procedure to its offerings: transcarotid artery revascularization, or TCAR.

This procedure is an alternative method to treat carotid artery blockages with a stent in patients who are not candidates for carotid endarterectomy — long considered the gold standard surgery.

TCAR allows surgeons to deliver and place a stent directly into the carotid artery through a small incision in the neck. This approach uses technology that temporarily reverses blood flow from the artery to a vein in the groin, keeping plaque particles that could be disturbed during the procedure from flowing toward the brain, thereby reducing the risk for stroke. At Johns Hopkins. vascular surgeons Caitlin Hicks and Christopher Abularrage perform the procedure.

“TCAR is meant to be equivalent to a regular carotid stent, which you usually go through the groin to do,” says Hicks. “But it avoids having to pass catheters and wires through the aortic arch, which is where a lot of people have calcium, and where a lot of the risk of stroke is. We make a small cut just above the clavicle to access the carotid artery directly and put a stent in that way.”

Good candidates for the procedure typically are people who can’t have surgery either because of heart or lung disease, previous neck surgeries or radiation, or those who are intolerant to anesthesia, Hicks says. TCAR can be performed with patients awake or asleep, and they generally remain in the hospital overnight for evaluation before returning home.

While the procedure is offered selectively, Hicks says, “we have excellent results with the patients we have treated, and the literature from general use of the procedure in the U.S. demonstrates that the stroke rates are better than for transfemoral carotid stents and may be approaching those of carotid endarterectomy, although further studies are necessary.”

For the majority of patients, says Perler, carotid endarterectomy remains the conventional treatment. It is performed through a small incision in the neck to directly remove plaque and blood clots and is used to prevent strokes in patients who have symptoms of arterial disease and narrowing of the arteries, or in patients who do not have symptoms but have more severe blockages. It, too, can be performed while patients are awake or asleep.

The division additionally offers transfemoral carotid artery angioplasty with stenting, an option for people who are unable to have carotid endarterectomy due to their overall medical or surgical risk. In the procedure, a small catheter is threaded through a blood vessel in the groin to the carotid arteries. Once in place, a balloon is inflated to open the artery and a stent placed to hold the artery open.

Many patients with carotid disease can also be managed through lifestyle changes and medications to lower cholesterol, lower blood pressure and prevent blood clots, Perler says, as well as regular follow-up visits that use ultrasound scans to measure arterial plaque. 

“When you come to Johns Hopkins, you get a comprehensive evaluation and the care that you most need,” says Perler. “We’re very proud of our culture and how we put the patient’s best interests first.”

Podcast: Treatment of Carotid Artery Disease