Premier Surgical Vascular Surgeons are among the first in Knoxville to use an innovative procedure that can help prevent stroke in patients during carotid artery surgery.

TransCarotid Artery Revascularization or TCAR is a procedure that combines two previously known procedures – carotid endarterectomy or CEA, and carotid artery stenting or CAS.

Dr. Afshin Skibba, Vascular Surgeon

Premier Vascular Surgeon Dr. Afshin Skibba was the first to perform the TCAR technique at Fort Sanders Regional Medical Center in Knoxville. The hospital was recently recognized as a Center of Excellence for TCAR. There are only three facilities in the Tennessee and Mississippi region that have been awarded this prestigious recognition.

This recognition designates that Fort Sanders Regional stands out both in handling a significant volume of TCAR procedures, as well as having excellent TCAR outcomes.

To learn more about this procedure, we spoke with Dr. Skibba.

What is TCAR?
Before TransCarotid Artery Revascularization (TCAR), carotid endarterectomy (CEA) had been the gold standard for carotid revascularization. This procedure involves opening the neck, fixing the artery, then repairing it with a patch, and has good outcomes. Then, carotid artery stenting (CAS) became available, allowing the carotid lesion to be fixed via a needle stick in the groin or in the arm. CAS has been used only sparingly as the risk of stroke is substantially higher with CAS compared with CEA.

The TCAR procedure prevents plaque from traveling to the brain during carotid artery surgery.

Then TCAR became available. This procedure takes the best features of CEA and CAS and combines then into one procedure. With TCAR, the carotid lesion is fixed with a stent and balloon, but under the conditions of reversed blood flow in the carotid artery, such that any debris that is liberated during that process exit the body and is caught in a filter, rather than traveling to the brain and causing a stroke. The risk of stroke of TCAR is lower than both CEA and CAS and is the lowest reported to date.

How does TCAR help patients who may be at risk for strokes?
With TCAR, a small incision is made above the collarbone to expose the common carotid artery. A surgeon places a soft, flexible sheath into the carotid artery, connecting it to a system that reverses the blood flow away from the brain. This protects the brain from possible debris such as fragments of plaque that may come loose during the procedure.

The blood is then filtered and returned to a second sheath placed in the patient’s femoral vein in the groin. This allows stenting to be performed (to clear blockages) while the blood flow is reversed. Once the stent is placed, the flow reversal is turned off and normal blood flow to the brain resumes.

Aside from having a lower risk of stroke, TCAR also has a lower risk of cranial nerve trouble, of blood transfusion issues, heart attacks, and abnormal heart rhythms, and other complications associated with carotid artery procedures, when compared to CEA.

Who are the best candidates for TCAR?
The majority of patients who need a carotid intervention qualify for a TCAR. Specifically, to qualify, the patient must meet either one of a number of medical high-risk criteria, or one of a number of anatomic high-risk criteria, which is determined by the vascular surgeon.

To learn more about the TCAR procedure and the Premier Surgical Vascular Surgeons who perform it, visit our TCAR webpage at


Other references: