Clear Passages

Carilion’s Dr. Joshua Adams first in southwest Virginia, second in state to perform minimally invasive TCAR procedure.

Dr. Joshua Adams

Photo courtesy of Carilion Clinic

Vinton resident Ron Minnix, 72, was suffering from carotid artery stenosis—a narrowing of the arteries on either side of the neck, due to plaque buildup—leaving him at risk for a stroke. He’d already had surgery to remove the plaque from his left carotid artery; now, several years later, he had a 90 percent blockage on his right side. Vascular intervention radiologist and vascular surgeon Dr. Joshua Adams, the director of Carilion Clinic Aortic Center, suggested a new hybrid treatment called TransCarotid Artery Revascularization (TCAR). 

Minnix’s first surgery had required general anesthesia and a large incision. TCAR is essentially the opposite, explains Adams. “We do these cases with the patient awake. We put local numbing medicine at the base of the neck and we make a very small transverse incision.”

Guided by imaging, Adams places a sheath inside the carotid artery to access the area leading to the brain. He then reverses the blood flow, using a circuit outside of the body. The blood is filtered and returned through a second sheath placed in the femoral vein in the patient’s thigh. He then crosses the blockage with a wire, opens it with a balloon angioplasty, and stents the area. “Anytime during those [last] three steps, the patient is at risk for particles breaking free from the plaque. But because we’ve got the flow reversed, the particles are captured by the circuit and don’t go to the brain and create a stroke,” he says. Blood can still travel up to the brain via three other arteries. “We actually have a very redundant system as far as getting blood up to the brain.” Once the stenting is complete, the neuroprotective circuit is turned off and normal blood flow returns.

TCAR has a similar risk of stroke as the open procedure—about 1 to 1.3 percent—and an equally low risk of perioperative mortality or cardiac events. TCAR patients are also three times less likely to suffer injuries to the cranial nerves, which help with swallowing and other important functions, “because you’re doing a limited incision at the base of the neck instead of dissecting out the entire carotid artery,” says Adams. 

Additionally, TCAR patients have significantly less post-operative pain and a shorter hospital stay than open surgery patients—usually no more than one night.

In June 2018 Minnix became the second patient at Carilion Roanoke Memorial Hospital to have undergone TCAR. In contrast to his first surgery, where he suffered pain for several days, he says, “With the TCAR, I had no pain whatsoever. Once the procedure was done, I was ready to go home. It was so much easier.”

This article originally appeared in our December 2018 issue.

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