Tag Archives: TCAR

Anatomy = Technology?

Hey all, it’s been a long time. I am currently half way through the interview trail for 5+0 vascular surgery residency. It’s been busy, sometimes hectic, but definitely eye-opening and fulfilling experience. Visiting top-notch institutions, poking the brains of well-trained and well-researched surgeons, learning about the forefront clinical trials are all part of the interviewing experience that make the $100+ per night hotel stay and 20 hour per week at the airport worthwhile.
To keep this blog topic anonymous, let’s just say when I interviewed at a certain top 10 hospital, I had a pre-interview dinner with Dr. A. Dr. A is a sage who has been practicing vascular surgery all of his life, and who generously extended me the advice of making sure the “anatomy matches technology”.
When he spoke of this philosophical concept, his goal was to tell me to learn all of the options available in vascular surgery, choose what is most appropriate, and draw up plan B, C, D, etc since you have all of the options up your sleeve. This is a great advice, and frankly the most fascinating aspect of vascular surgery in my opinion. Having many ways of treating the same lesion is both interesting and cognitively challenging.
Let me give you an example of the philosophy of “anatomy = technology” in real life vascular surgery that made this concept really resonate with me. There is a new technique of treating carotid lesion that have developed in the past few years called TCAR (trans-carotid artery revascularization). To make a long description short, it utilizes flow reversal from common carotid artery to femoral vein to prevent distal embolization, while allowing a small incision above the clavicle for proximal control and to be the site of angioplasty/stenting, obviating the need to traverse through a hostile aortic arch in trans-femoral approach. Research (ROADSTER trials) has shown that the composite rate of stroke, death and MI rate 30 days after TCAR is smaller than traditional carotid endarterectomy. The vascular surgery world is pretty much split on whether TCAR should be more widely used, as it is currently only indicated for distal internal carotid lesion, high risk patient, redo/irradiated neck, etc as it is for transfemoral carotid stenting. You might ask yourself, what is not to like about TCAR, something that can save patients surgical wound, multiple days of hospital stay, and potentially fewer perioperative stroke?
I urge you to look at new device and technique development with open-mindedness but an objective attitude. This is a classic case of the necessity of making sure that “anatomy matches technology”. Sure, having TCAR allows patient with risky neck or high risk aortic arch to benefit from a small supraclavicular incision. Nevertheless, the traditional carotid endarterectomy is actually a very low risk procedure especially in the hand of a well-trained, experienced vascular surgeon. Some cite the stroke rate of less than 0.2%! For these surgeons, learning a new technique, and most importantly subjecting patient to a procedure that would cost them thousands of more dollars and one that still lacks long term data is much worse. For those of us who are more enthusiastic about TCAR (because it is after all another option in the repertoire), perhaps the right thing to do for now is to learn it well, but still discuss with the patient the possibility of referring to a surgeon with good endarterectomy outcome, if it is not us.
Being cool and cutting-edge is one thing, but individualizing to each patient and doing what’s best for the patient is the rule.