In this supplement, we aim to share important insights that have been gained in the last 4 years since transcarotid artery revascularization (TCAR) became commercially available.

In those 4 short years, TCAR has rapidly risen to become a powerful weapon in the armamentarium of stroke prevention by carotid revascularization. It has consistently shown procedural safety in terms of stroke hazard that is equivalent to carotid endarterectomy (CEA) and that far surpasses that of transfemoral carotid artery stenting (CAS) while affording additional efficiency advantages such as procedure time, “clamp time” equivalent, length of stay, etc.

Data analyzed from the Society for Vascular Surgery Vascular Quality Initiative (VQI) TCAR Surveillance Project are shared here in this supplement. These data are unique in that they are independent of Silk Road Medical Inc. and represent the “real world” in every sense. As data entry into the VQI is a condition of reimbursement for most TCARs performed in the United States, this data set represents the outcomes for first ever TCARs performed by first-time TCAR operators after attending a training program (TEST DRIVE). There is no allocation given to learning curve, thus the data assimilate first experiences.

We provide guidance in building your TCAR program, positioning of TCAR versus alternatives, advice on “conjoint” pathways for two specialties working together, practical tips on the “choreography” between team members in the operating room/hybrid suite environment, and answers to commonly asked question such as “what should one do when faced with stent restenosis,” appreciating that this entity is uncommon. We share crucial details about bifurcation lesions that may prove challenging and those (the majority) that are straightforward for TCAR, provide guidance around “in the moment” decision-making in those infrequent cases in which early recognition of a potential problem will usually avert a complication. We detail shared decision-making, an often overlooked aspect of consent but one that is championed by Medicare. Last, but certainly not least, is a nod to the future; fellows and their unique training requirements.

Our overarching aim is the support of your TCAR patients and your TCAR program—we hope that you find this TCAR supplement both useful and interesting.

Finally, I would like to acknowledge early innovators, David W. Chang, MD, and Enrique Criado, MD, for their pioneering work in transcarotid therapies.

Sumaira Macdonald, MD, PhD, MBChB, MRCP, FRCP, FRCR, EBIR
Vascular Interventional Radiologist
Executive Medical Director
Silk Road Medical
Sunnyvale, California
Disclosures: None.