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

Objective: The aim of this study was to provide early-term evaluation, safety, and efficacy of the novel CGuard (Inspire MD, Tel Aviv, Israel) micromesh self-expanding stent with embolic protection system (EPS) during carotid artery stenting (CAS) procedure. Materials and Methods: All patients who underwent CAS with CGuard carotid stent system from January 2018 to September 2020 in a tertiary center were prospectively evaluated. Primary endpoints included technical success and perioperative neurological events (0–48 hours). Secondary endpoint was the rate of neurologic, cardiac events, and death (major adverse event or MAE) at 30 days. Patency of CGuard, peak systolic velocity (PSV), and end diastolic velocity (EDV) were evaluated at 30 days with duplex ultrasound. Results: A total of 103 patients underwent CAS procedure. Forty patients were symptomatic, and 63 patients were asymptomatic with stenosis greater than 70%. Technical success was 100%. Local anesthesia was applied in 94 patients (93%). Embolic protection devices were used in 6 patients (5.8%). Access site complications were 1.9%. Mean internal carotid artery stenosis diameter reduced from 79.47% to 14.68%. Two patients had transient ischemic attack (1.9%) and 1 patient experienced a cerebral hyperperfusion syndrome (CHS) perioperatively. External carotid artery (ECA) occlusion occurred in 1.9%. Four patients experienced jaw claudication (3.8%) postoperatively. Mean time of operation was 41 minutes. Mean duration of hospitalization was 3.1 days. The 30-day rate of MAE was 0%. CGuard patency was 100%, mean internal carotid PSV was reduced from 251.57 to 77.29 cm/s, and mean internal carotid EDV was reduced from 154.62 to 24.63 cm/s at 30 days. Conclusion: Our study shows that CGuard stent with EPS is an effective and safe device for treatment of carotid artery stenosis with acceptable low perioperative neurologic events, even with low embolic protection device usage. Larger multicenter and randomized studies are necessary to confirm its long-term efficacy.

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CaRotid Artery Filtering Technique (CRAFT): A Technique for Carotid Artery Stenting with Intrinsic Embolic Protection

Neurointervention ◽

10.5469/neuroint.2021.00353 ◽

2021 ◽

Author(s):

Michelle Foo ◽

Yifan Ren ◽

Jay Gajera ◽

Christen D Barras ◽

Hong Kuan Kok ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenosis ◽

Carotid Artery Stenting ◽

Stroke Risk ◽

Artery Stenosis ◽

Embolic Stroke ◽

Stent Deployment ◽

Symptomatic Carotid ◽

Embolic Protection ◽

Filtering Technique

Purpose: Carotid artery stenting (CAS) is an established treatment for symptomatic carotid artery stenosis as an alternative to carotid endarterectomy. A variety of techniques and devices have been devised to minimise periprocedural stroke risk using either proximal or distal embolic protection. This study presents a method of embolic protection during CAS–the CaRotid Artery Filtering Technique (CRAFT).Materials and Methods: The CRAFT technique employs aspects of both proximal and distal embolic protection. The CASPER RX stent (MicroVention, Tustin, CA, USA), which is a double-layered, closed-cell, micromesh nitinol stent, is deployed across the carotid artery stenosis with the assistance of a FlowGate balloon guide catheter (Stryker Neurovascular, Fremont, CA, USA). The partially deployed stent acts as a distal filter while the balloon guide is deflated midway during stent deployment to prevent distal plaque embolisation, followed by completion of stent deployment and angioplasty.Results: A total of 94 patients underwent CAS using the CRAFT technique between June 2016 and March 2021. Successful stent deployment was achieved in all patients. Preliminary results demonstrated acute stent occlusion in 6 patients (6.4%) and distal embolic stroke in 5 patients (5.3%). The median procedural fluoroscopy time was 34 minutes with an interquartile range of 22 to 55 minutes.Conclusion: The CRAFT technique of CAS presented by this study can be applied in the treatment of symptomatic carotid artery stenosis in both emergency and elective procedure settings with a high technical success and low distal embolic stroke risk.

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Endovascular Advances for Extracranial Carotid Stenosis

Neurosurgery ◽

10.1227/neu.0000000000000223 ◽

2014 ◽

Vol 74 (suppl_1) ◽

pp. S92-S101 ◽

Cited By ~ 1

Author(s):

Jorge L. Eller ◽

Travis M. Dumont ◽

Grant C. Sorkin ◽

Maxim Mokin ◽

Elad I. Levy ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Stenosis ◽

Carotid Artery Stenosis ◽

Carotid Artery Stenting ◽

Carotid Stenting ◽

Historical Background ◽

Treatment Modalities ◽

Endovascular Management ◽

The Past

Abstract Carotid artery stenting has become a viable alternative to carotid endarterectomy in the management of carotid stenosis. Over the past 20 years, many trials have attempted to compare both treatment modalities and establish the indications for each one, depending on clinical and anatomic features presented by patients. Concurrently, carotid stenting techniques and devices have evolved and made endovascular management of carotid stenosis safe and effective. Among the most important innovations are devices for distal and proximal embolic protection and new stent designs. This paper reviews these advances in the endovascular management of carotid artery stenosis within the context of the historical background.

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Effect of Carotid Artery Stenting on Cognitive Function in Patients With Carotid Artery Stenosis: Preliminary Results

American Journal of Neuroradiology ◽

10.3174/ajnr.a0828 ◽

2008 ◽

Vol 29 (2) ◽

pp. 265-268 ◽

Cited By ~ 30

Author(s):

A.S. Turk ◽

I. Chaudry ◽

V.M. Haughton ◽

B.P. Hermann ◽

H.A. Rowley ◽

...

Keyword(s):

Cognitive Function ◽

Carotid Artery ◽

Carotid Artery Stenosis ◽

Carotid Artery Stenting ◽

Artery Stenosis ◽

Preliminary Results

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Transcarotid Artery Revascularization and Advances in Vascular Surgery for Carotid Artery Disease

Surgical Technology Online ◽

10.52198/21.sti.39.cv1484 ◽

2021 ◽

Author(s):

James Hu ◽

◽

Andy Sohn ◽

Justin George ◽

Rajesh Malik ◽

...

Keyword(s):

Carotid Artery ◽

Vascular Surgery ◽

Carotid Endarterectomy ◽

Surgical Management ◽

Carotid Artery Stenosis ◽

Carotid Artery Stenting ◽

Carotid Artery Disease ◽

Artery Stenosis ◽

Cerebrovascular Accidents ◽

Artery Disease

Carotid artery atherosclerotic disease impacts over 2 million Americans annually. Since the advent of the carotid endarterectomy by Debakey in 1953, the surgical management of carotid artery stenosis has prevented cerebrovascular accidents. The technology utilized to manage carotid artery stenosis continued to evolve with the utilization of carotid artery stenting in 1989 and more recently transcarotid artery revascularization (TCAR). This review discusses the modern management of carotid artery stenosis with an emphasis on transcarotid artery revascularization (TCAR) and reversal of flow for reversal of flow for embolic protection.

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