Usefulness of dual protection combined with blood aspiration for distal embolic protection during carotid artery stenting

BackgroundCarotid artery stenting (CAS) for internal carotid artery (ICA) stenosis with vulnerable plaques is controversial. We analyzed the effect of a dual protection and blood aspiration method during CAS in patients with vulnerable plaques.MethodsA total of 111 patients with ICA stenosis underwent CAS using the dual protection (simultaneous flow reversal and distal filter) and blood aspiration method. In 103 of 111 patients, preoperative carotid plaque was estimated by both 3 T MRI and ultrasonography (US). ICA plaques with a high intensity signal on time-of-flight-MR angiography (TOF-MRA) and/or mobile component on US were defined as vulnerable plaques. We assessed major adverse events (MAE) (ie, major stroke, myocardial infarction, and death) and hyperintense spots on diffusion-weighted images (DWI) after CAS. We then evaluated the visible debris captured by dual protection and blood aspiration during CAS.ResultsThe preoperative ICA plaque on TOF-MRA and US was judged to be vulnerable in 48.5% (50/103 patients). The success rate of the CAS procedure was 100% with no MAE within 30 days. DWI showed small hyperintense spots in 18% (9/50 patients) and 18.9% (10/53 patients) in the vulnerable and non-vulnerable plaque groups, respectively. Visible debris was captured in 68% (34/50 patients) and 45.3% (24/53 patients) in the vulnerable and non-vulnerable plaque groups, respectively (p=0.0286).ConclusionsThe combination of dual protection and blood aspiration could provide effective distal embolic protection although vulnerable plaques on TOF-MRA and US had a high incidence of debris during CAS. Thus, CAS using dual protection and blood aspiration is safe in patients with vulnerable plaques.

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Comparison of dual protection and distal filter protection as a distal embolic protection method during carotid artery stenting: a single-center carotid artery stenting experience

Neurosurgical Review ◽

10.1007/s10143-015-0639-x ◽

2015 ◽

Vol 38 (4) ◽

pp. 671-676 ◽

Cited By ~ 8

Author(s):

Yosuke Kajihara ◽

Shigeyuki Sakamoto ◽

Yoshihiro Kiura ◽

Kazutoshi Mukada ◽

Takahiro Chaki ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenting ◽

Single Center ◽

Embolic Protection ◽

Protection Method ◽

Dual Protection ◽

Distal Filter

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Safety of carotid artery stenting for elderly patients with cervical carotid artery stenosis

Interventional Neuroradiology ◽

10.1177/1591019919900831 ◽

2020 ◽

Vol 26 (4) ◽

pp. 439-445

Author(s):

Akira Taguchi ◽

Shigeyuki Sakamoto ◽

Takahito Okazaki ◽

Jumpei Oshita ◽

Masashi Kuwabara ◽

...

Keyword(s):

Carotid Artery ◽

Adverse Events ◽

Elderly Patients ◽

Carotid Artery Stenting ◽

Minor Stroke ◽

Diffusion Weighted Images ◽

Diffusion Weighted ◽

Dual Protection ◽

Blood Aspiration ◽

Major Adverse Events

Background Several recent randomized controlled trials have reported that perioperative complications of carotid artery stenting increase with age, and Japan has the highest proportion of elderly in the world. We retrospectively compared clinical factors, treatment outcomes, and adverse events between younger and elderly carotid artery stenting patients at a single institution in Japan to assess carotid artery stenting safety for the aged population. Methods A total of 150 consecutive patients treated with carotid artery stenting using the dual protection (simultaneous flow reversal and distal filter) and blood aspiration method were enrolled. Patients were classified into an elderly (O) group ≥75 years (54/150, 36.0%) and a younger (Y) group <75 years (96/150, 64%) for comparison of demographics, clinical background, incidence of captured debris during the procedure, outcome, minor stroke, major adverse events (major stroke, myocardial infarction, or death) within 30 days, hyperintense spots on diffusion-weighted images after carotid artery stenting, and postoperative hospitalization days. Results The carotid artery stenting procedure was successful in all cases. No major adverse events occurred within 30 days in the Y group, and only one occurred in the O group ( P = 0.348). Visible debris was captured in a significantly greater proportion of O group patients than in Y group patients (33/54 (63.5%) vs. 40/96 (42.1%), P = 0.016), but there was no significant difference in the frequency of hyperintense spots on diffusion-weighted images between Y and O groups (23/96 (24.0%) vs. 16/52 (30.8%), P = 0.435). Conclusions Carotid artery stenting using dual protection and blood aspiration is equally safe for younger and elderly patients.

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Risk Factors for Cerebral Embolization After Carotid Artery Stenting With Embolic Protection

Circulation Cardiovascular Interventions ◽

10.1161/circinterventions.112.000093 ◽

2013 ◽

Vol 6 (3) ◽

pp. 311-316 ◽

Cited By ~ 24

Author(s):

Klaudija Bijuklic ◽

Andreas Wandler ◽

Yuriy Varnakov ◽

Thilo Tuebler ◽

Joachim Schofer

Keyword(s):

Risk Factors ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

Embolic Protection ◽

Cerebral Embolization

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Abstract P540: Safety of Carotid Artery Stenting Without Embolic Protection: A Single Centre Experience

Stroke ◽

10.1161/str.52.suppl_1.p540 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Christine Hawkes ◽

Aviraj Deshmukh ◽

Brian van Adel

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

Atheromatous Plaque ◽

Stroke Rate ◽

Protection Device ◽

Single Centre ◽

Stent Occlusion ◽

Embolic Protection Device ◽

Embolic Protection

Introduction: One of the most feared complications of carotid revascularization, including carotid artery stenting (CAS), is peri-procedural ischemic stroke. Several studies suggest that the use of a distal embolic protection device (EPD), as well as over-sized pre- and post-stenting balloon angioplasty, may increase the risk of dislodgement of atheromatous plaque in patients undergoing CAS. The CREST trial, that mandated the use of an EPD, had a peri-procedural ischemic stroke rate of 4.1%. We hypothesize that our technique of stenting without the use of an EPD and sub-maximal angioplasty will have a low risk of peri-procedural complications. Methods: A retrospective review was conducted of consecutive cases of ICA stenting without use of an embolic protection device between January 2012 and June 2020 at a Canadian stroke centre. Data was extracted from the patient electronic medical record and Picture Archives and Communications Systems (PACS). Both symptomatic and asymptomatic CAS cases were included. Results: A total of 220 patients were included in the study, with a median age of 70 years (range 39-93 years), and 83 patients (38%) were female. The vast majority of patients were symptomatic (216 patients [98%]). A large portion of patients had a contralateral ICA occlusion or near occlusion (56 patients [25%]). In the majority of cases, a Precise Cordis RX carotid stent (Cordis) was placed. There were four patients with peri-procedural ischemic strokes (1.8%), with two occurring 8-30 days after stenting. There was one case of acute stent occlusion associated with an ischemic stroke. Two patients (less than 1%) had hyperperfusion syndrome after CAS. Median length of stay following the procedure was one day. Conclusions: In this single centre series, the peri-procedural risks of CAS without using an EPD are low. The ischemic stroke rate is less than 2%, lower than what has been reported in large randomized controlled trials using embolic protection.

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CRT-300.04 Comparison of Devices in Carotid Artery Stenting: A Vascular Quality Initiative Analysis of Commonly Used Carotid Stents and Embolic Protection Devices

JACC Cardiovascular Interventions ◽

10.1016/j.jcin.2016.12.146 ◽

2017 ◽

Vol 10 (3) ◽

pp. S41

Author(s):

Ashwat S. Dhillon ◽

Sisi Li ◽

Juan Pablo Lewinger ◽

Leonardo C. Clavijo ◽

David M. Shavelle ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenting ◽

Embolic Protection ◽

Protection Devices

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The role of transfemoral carotid artery stenting with proximal balloon occlusion embolic protection in the contemporary endovascular management of carotid artery stenosis

Journal of Vascular Surgery ◽

10.1016/j.jvs.2020.02.036 ◽

2020 ◽

Vol 72 (5) ◽

pp. 1701-1710 ◽

Cited By ~ 1

Author(s):

Patric Liang ◽

Peter Soden ◽

Mark C. Wyers ◽

Mahmoud B. Malas ◽

Brian W. Nolan ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenosis ◽

Carotid Artery Stenting ◽

Balloon Occlusion ◽

Artery Stenosis ◽

Endovascular Management ◽

Embolic Protection

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Postoperative ischemic events in patients undergoing carotid artery stenting using algorithmic selection for embolic protection

The Neuroradiology Journal ◽

10.1177/1971400919839644 ◽

2019 ◽

Vol 32 (4) ◽

pp. 294-302 ◽

Cited By ~ 1

Author(s):

Yasuhiro Kawabata ◽

Norio Nakajima ◽

Hidenori Miyake ◽

Shunichi Fukuda ◽

Tetsuya Tsukahara

Keyword(s):

High Risk ◽

Carotid Artery ◽

Carotid Endarterectomy ◽

Transient Ischemic Attack ◽

Carotid Artery Stenting ◽

Minor Stroke ◽

High Risk Patients ◽

Embolic Protection ◽

Risk Patients ◽

Ischemic Attack

Purpose Carotid artery stenting (CAS) is a valuable alternative to carotid endarterectomy, especially in high-risk patients. However, the reported incidences of perioperative stroke and death remain higher than for carotid endarterectomy, even when using embolic protection devices (EPDs) during CAS. Our purpose was to evaluate 30-day major adverse events after CAS when selecting the most appropriate EPD. Methods We reviewed the clinical outcomes of 61 patients with 64 lesions who underwent CAS with EPDs. Patients who underwent CAS associated with thrombectomy and who had a preoperative modified Rankin scale score >3 were excluded from the analysis. The EPD was selected based on symptoms, carotid wall magnetic resonance imaging and lesion length, and we analyzed combined 30-day complication rates (transient ischemic attack, minor stroke, major stroke or death). Results Forty-nine patients were men and 12 were women. The median age was 72 years (range: 59–89 years) and 44 lesions were asymptomatic. A filter-type EPD was selected in 23 procedures, distal-balloon protection in 14 procedures and proximal-occlusive protection in 27 procedures. Two patients (3.1%) experienced a transient ischemic attack and one patient (1.6%) had a minor stroke within 30 days of the procedure. No patients experienced procedure-related morbidities (modified Rankin score >2) or death. Conclusions The perioperative stoke rate was low when we selected a proximal-occlusive-type EPD in high-risk patients with vulnerable carotid artery disease. Our algorithm for EPD selection was an effective tool in the perioperative management of carotid artery stenosis.

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