Stroke prevention: new procedure goes against the flow

January 9th, 2018

The time had come, Diana Rogers knew. She heard the quiet whistling of blood as it squeezed through the severely narrowed carotid artery on the right side of her neck when she lay still. She felt a constant, dull pressure behind her eyes. And less physically but no less a burden, she carried the knowledge that the plaques blocking about 90 percent of the artery could break free at any time and cause a stroke possibly ending her life.

“It affects your behavior. It affects everything,” Rogers said. “You end up in a bubble of fear.”

Carotid artery plaques building up, breaking off and blocking blood flow in the brain are to blame for a quarter or more of all strokes. Rogers’s 64-year-old body has a frustrating tendency toward atherosclerosis, and she has several artery-widening stents to show for it. In 2008, the plaques in her left carotid artery had gotten to the point that an open carotid endartorectormy, or CEA, had to happen. It involves a vascular surgeon clamping the artery and manually clearing out the plaque. It worked, and she has a faint, white scar tracing eight inches from her neck as a reminder that it did.

This time, though, it would take something different. CEAs are still the standard of care, said Omid Jazaeri, MD, a University of Colorado School of Medicine vascular surgeon practicing at the UCHealth Heart and Vascular Center on the Anschutz Medical Campus. But Rogers, slowed by pulmonary arterial hypertension that has her supplemental oxygen flowing through a tracheostomy tube, is no longer a candidate for that sort of invasive surgery for stroke prevention. She would need a stent to press the narrowed carotid artery wider.

A new route for stroke prevention

Until recently, such stents were threaded through the femoral artery near the groin, up through the aorta and into the carotid artery. Carotid artery stenting has a long track record. But in cases like that of Rogers, there’s risk of the stent-bearing catheter and other wires knocking plaque loose – in particular from the aortic arch above the heart – and causing the sorts of strokes the procedure was designed to prevent. Fortunately, Jazaeri had another option.

Portraite of Dr. Omid Jazaeri
Dr. Omid Jazaeri is the first in the state to perform TCAR, a surgery that improves stroke prevention.

It’s called transcarotid artery revascularization, or TCAR, and it’s done using Silk Road Medical’s ENROUTE Transcarotid Neuroprotection System. That’s a mouthful, but it’s straightforward enough. Rather than the catheter delivering the carotid stent all the way from the groin, surgeons insert it through a small incision in the neck, just a couple of inches from the blockage to boost stroke prevention.

“This procedure avoids the anatomy that can be problematic and can flick off clot or debris that can head up north,” Jazaeri said.

In addition, the system involves a mechanism that reverses the flow of blood in the carotid artery as the stent is placed – when stroke-causing plaques also can be jarred loose. The blood runs backwards through a filter to capture any loose plaque and then feeds back into the femoral vein.

The U.S. Food and Drug Administration approved TCAR in February 2015, citing clinical trial results that showed just 1.4 percent of TCAR patients had strokes in the 30 days following surgery, compared to 2.3 percent among those who underwent the CEA procedure Rogers had done in 2008. That’s about 40 percent less risk.

Jazaeri went to Chicago to train on TCAR and, in November, performed Colorado’s first TCAR procedure. Rogers was the second patient, on November 30. The whole procedure took about an hour, a small investment to help with stroke prevention.

‘Another tool in the box’

Less than two weeks later, she and her husband David talked about the experience over lunch at UCHealth University of Colorado Hospital’s Garden View Café. The uninitiated might have assumed the woman with the big smile and purple and pink highlights in her hair was here to visit a patient and not a patient herself. She and David make the trip up from Walsenburg every three weeks, staying overnight near campus and batching medical appointments. She shifted her bright purple scarf to show the difference in the 2008 and 2017 scars. The new one was horizontal, about an inch-and-a-half long.

“I mean, it was like having a Band-Aid,” Rogers said. “They glued it shut.”

The nighttime whisper of blood is gone, as is the pressure behind her eyes. So are the migraine headaches she had long dealt with. She is happy with what she described as “the new normal inside my head.”

“That might be a placebo effect,” David suggested.

“I’ll take it,” she said.

Jazaeri, who had performed three TCAR procedures by mid-December, said that for patients strong enough to handle it, carotid endartorectormy remains the gold standard. But for high-risk patients such as Rogers, TCAR is, as he put it, “another tool in our box to help prevent strokes.”

Jazaeri said TCAR-like procedures can boost stroke prevention by temporarily reversing blood flow may one day expand to neurological interventions. “The short distance to blockages or aneurysms in the brain makes this new system very attractive for future interventions above the level of the neck arteries.”

“There’s huge potential for future research and technology development,” he said.

Rogers would certainly recommend the procedure Jazaeri is doing already.

“Oh my, yes,” she said. “In a heartbeat.”