Experimental and Computational Evaluation of Embolic Protection

2010 ◽  
Author(s):  
Gail M. Siewiorek ◽  
Ender A. Finol
Keyword(s):  
Carotid Artery ◽  
The Body ◽  
Cerebral Vasculature ◽  
Treatment Alternative ◽  
Computational Evaluation ◽  
Protection Devices ◽  
Distal Protection ◽  
Distal Perfusion ◽  
Viable Treatment

Carotid artery stenting (CAS), an endovascular treatment for severe carotid artery occlusive disease, is increasingly considered a complimentary procedure to carotid endarterectomy. One reason for the acceptance of CAS as a viable treatment alternative is cerebral protection devices (CPDs), which can reduce the embolic load in the cerebral vasculature. One particular type of CPD, distal protection filters (DPFs), are a popular choice due to their ability to allow distal perfusion peri-procedurally while filtering and removing plaque emboli from the body. This investigation studied one FDA-approved DPF, RX Accunet, using both in vitro and computational methods.

In Vitro Performance Assessment of Distal Protection Devices for Carotid Artery Stenting: Effect of Physiological Anatomy on Vascular Resistance

2007 ◽  
Vol 14 (5) ◽  
pp. 712-724 ◽  
Author(s):  
Gail M. Siewiorek ◽  
Mark H. Wholey ◽  
Ender A. Finol
Keyword(s):  
Carotid Artery ◽  
Pressure Gradient ◽  
Vascular Resistance ◽  
Flow Rate ◽  
Volume Flow Rate ◽  
Volume Flow ◽  
Physiological Anatomy ◽  
Protection Devices ◽  
Distal Protection

Purpose: To assess in vitro the performance of 5 distal protection devices (DPDs) by evaluating the capture efficiency, pressure gradient, volume flow rate, and vascular resistance in the internal carotid artery (ICA). Methods: The time-averaged mean peak velocity in the common carotid artery and a blood-mimicking solution were used to simulate physiological conditions in a silicone carotid phantom representing average human carotid artery geometry with a 70% symmetrical ICA stenosis. Five milligrams of dyed 200-μm nominal diameter polymer microspheres (larger than the pore size of the devices, except Spider RX, which was tested with 300-μm-diameter particles) were injected into the ICA. The percentages of particles missed after injection and lost during device retrieval were measured for the 5 devices (Spider RX, FilterWire EZ, RX Accunet, Angioguard XP, and Emboshield). The normalized pressure gradient, fraction of the volume flow rate, and vascular resistance in the ICA were calculated. Results: Spider RX captured the most particles (missing 0.06%, p<0.05) and yielded the smallest normalized pressure gradient increase (4.2%), the largest volume flow rate fraction (0.40), and the smallest vascular resistance in the ICA (272 mmHg/L·min−1, a 5.4% increase with respect to initial conditions). Angioguard XP captured the fewest particles (missing 36.3%, p<0.05 except Emboshield) and resulted in the largest normalized pressure gradient increase (37%) in the ICA. RX Accunet produced the smallest volume flow rate fraction in the ICA (0.30) and the largest vascular resistance in the ICA (470 mmHg/L·min−1, an 82.2% increase). Emboshield migrated ∼6 cm distal to the original position after particle injection. FilterWire EZ lost the fewest particles during retrieval (0.45%, p<0.05 except Accunet RX and Spider RX) and had the best overall performance with 200-μm emboli (p<0.05 except Accunet RX). Conclusion: None of the devices tested completely prevented embolization. Overall, Spider RX had the best performance and is conjectured to have the best wall apposition of the devices tested. Vascular resistance should be considered a key filter design parameter for performance testing since it represents a quantitative estimation of the “slow-flow phenomenon.” Our findings should be extrapolated cautiously to help interventionists choose the best device.

Permeability and Porosity of Embolic Protection Filters: An Experimental Study

2008 ◽  
Author(s):  
Gail M. Siewiorek ◽  
Ender A. Finol
Keyword(s):  
Carotid Artery ◽  
Flow Rate ◽  
Optimization Approach ◽  
Embolic Protection ◽  
High Resolution Images ◽  
Computational Fluid Dynamics Simulations ◽  
Protection Devices ◽  
Distal Perfusion ◽  
Dynamics Simulations

Endovascular therapies are an evolving form of treatment for stenosed atherosclerotic blood vessels. In particular, stenting and angioplasty of the carotid artery has recently gained more attention. Due to risk of periprocedural distal embolization, cerebral protection devices such as embolic protection filters (EPFs), which maintain distal perfusion during the intervention, have been developed to capture embolized plaque particles. This investigation studied in vitro the effects of a deployed EPF on flow rate in the internal carotid artery. The pseudopermeability of each device was calculated by maintaining a constant pressure gradient during its deployed state and after injection of emboli by adjusting the flow rate. High resolution images were used to calculate the porosity of each device. Experimentally-determined permeability and porosity can be used in computational fluid dynamics simulations as a design optimization approach to determine the optimal pore size for each EPF.

scholarly journals Percutaneous Angioplasty of the Sole Patent Cerebral Artery in Two Patients with Takayasu's Aortoarteritis

2016 ◽  
Vol 10 ◽  
pp. CMC.S38329
Author(s):  
Kiron Varghese ◽  
Srilakshmi M. Adhyapak
Keyword(s):  
Carotid Artery ◽  
Cerebral Artery ◽  
Balloon Angioplasty ◽  
Common Carotid Artery ◽  
Critical Stenosis ◽  
Neurological Event ◽  
Protection Devices ◽  
Distal Protection ◽  
The Right

We report two female patients with Takayasu's aortoarteritis, who presented with symptoms of cerebral ischemia due to critical stenosis of the sole patent cerebral artery. Both had occlusion of both vertebral arteries and one carotid artery with critical stenosis of the other carotid artery and presented with hemiparesis contralateral to the patent but stenosed cerebral artery. They also had transient ischemic attacks attributable to the culprit vessel. In the first patient, balloon angioplasty alone was not successful, and hence, a self-expanding stent was deployed in the right common carotid artery. In the second patient, successful balloon angioplasty was performed for the left common carotid artery. Distal protection devices were not used, and neither patient experienced any periprocedural neurological event. Clinical follow-up at six months revealed no significant cerebral events.

Endovascular Treatment of Innominate Artery Occlusion With Simultaneous Vertebral and Carotid Artery Distal Protection

Neurosurgery ◽  
2010 ◽  
Vol 66 (4) ◽  
pp. E843-E844 ◽  
Author(s):  
Michael F. Stiefel ◽  
Min S. Park ◽  
Cameron G. McDougall ◽  
Felipe C. Albuquerque
Keyword(s):  
Carotid Artery ◽  
Carotid Arteries ◽  
Innominate Artery ◽  
Artery Occlusion ◽  
Left Middle Cerebral Artery ◽  
Arterial Access ◽  
Atherosclerotic Stenosis ◽  
Protection Devices ◽  
Distal Protection ◽  
The Right

Abstract OBJECTIVE Atherosclerotic stenosis or obstruction of the innominate artery is rare. Traditional surgical management is a technically demanding intervention with acceptable, but not negligible, rates of morbidity and mortality. Endovascular approaches to supraaortic lesions have been successful and are now the preferred treatment for stenoses of the brachiocephalic vessels. The use of cerebral protection devices in subclavian and innominate interventions is less established. CLINICAL PRESENTATION A 58-year-old woman had Takayasu giant cell arteritis with a history of a left middle cerebral artery stroke 3 weeks after undergoing placement of a left common carotid artery (CCA) stent and right innominate artery stent in 1998. She recently presented with worsening dizziness, ataxia, and right arm numbness and was referred to the endovascular neurosurgery service for management. INTERVENTION Initial angiography revealed left CCA stenosis and right innominate occlusion. The patient initially underwent left CCA angioplasty, planned as a staged procedure. This was followed by recanalization of the right innominate artery through an approach using both femoral arteries and the right brachial artery. This 3-site technique allowed simultaneous distal protection of both the right cervical vertebral and carotid arteries. CONCLUSION Reopening a chronically occluded innominate artery risks an embolic shower through both the right vertebral and carotid arteries. Using multiple sites of arterial access, distal protection devices can be deployed in both the cervical vertebral and carotid arteries to reduce the risk of stroke.

Abstract 1122‐000174: Stroke Risk of Carotid Artery Stenting Using Balloon‐Guide Catheter Versus Distal Embolic Protection Devices

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Michael I Nahhas ◽  
Grant J Meeks ◽  
Juan Carlos Martinez‐Gutierrez ◽  
Gary R Spiegel ◽  
Yazan Alderazi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Focal Neurological Deficit ◽  
Embolic Protection ◽  
Guide Catheter ◽  
Primary Means ◽  
Protection Devices ◽  
Distal Protection ◽  
Proximal Occlusion

Introduction : Prevention of distal embolization during carotid artery stenting (CAS) is a key element of procedural technique and is standardly performed using distal protection devices (DPDs). Data in support of DPDs, however, are limited. Here, we present our experience of proximal occlusion using a balloon guide catheter (BGC) during CAS as the primary method of distal embolic protection. Methods : We conducted a retrospective review of patients undergoing CAS at our healthcare system between January of 2018 to March of 2021. Procedures were categorized by embolic protection strategy: DPD or BGC (with or without DPD). Emergent cases were defined as patients receiving CAS within <24 hours of presenting with an ischemic stroke or TIA ipsilateral to the carotid disease side. Severe stenosis was defined as 70–99% per NASCET criteria. The primary outcome was rate of procedural ischemic stroke between the DPD and BGC groups, and was defined as acute focal neurological deficit lasting for ≥ 24 hours following CAS related to an embolic event during the procedure. Results : A total of 126 CAS procedures were performed during the study period. 91 cases were performed under proximal BGC protection (of which 24 also included DPD usage) and 35 CAS cases via DPD as a primary mean for embolic protection. The median age for the cohort was 68 [IQR 62‐76], 37% females, 31% (n = 39) cases were treated emergently, and elective cases were 69% (n = 87). Baseline characteristics were similar in both groups except for hyperlipidemia (BGC vs DPD, 71.4% vs 42.9%; p = 0.003) and history of smoking (BGC vs DPD, 56% vs 34.4%; p = 0.029). Severe carotid stenosis was present in 80.2% BGC group and 77.1% in DPD (p = 0.573). Post‐stenting balloon angioplasty was more frequent in the BGC group as compared with DPD (54% vs. 26%, BGC vs. DPD, p = 0.005). Procedural embolic stroke rates were low in both groups, and not significantly different (1.1% vs. 2.9%, BGC vs. DPD, p = 0.48). Conclusions : CAS with BGC as the primary means of distal embolic protection showed comparable, low rates of procedural embolic ischemic events compared to those with DPD. These findings suggest BGC embolic strategies may be a viable alternative to DPD usage.

scholarly journals Predictors of adverse events complicating carotid artery stenting in the era of distal protection devices

2003 ◽  
Vol 41 (6) ◽  
pp. 52
Author(s):  
Ramtin Agah ◽  
Leslie Cho ◽  
Jacob Schneider ◽  
Albert W. Chan ◽  
Marco Roffi ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Adverse Events ◽  
Carotid Artery Stenting ◽  
Protection Devices ◽  
Distal Protection

scholarly journals What is the Real Risk of Dislodging Thrombi During Endovascular Revascularization of a Proximal Internal Carotid Artery Occlusion?

Neurosurgery ◽  
2011 ◽  
Vol 68 (4) ◽  
pp. 1084-1091
Author(s):  
Seung Kug Baik ◽  
Ungbae Jeon ◽  
Ki Seok Choo ◽  
Yong-Woo Kim ◽  
Kyung Pil-Park
Keyword(s):  
Carotid Artery ◽  
Internal Carotid ◽  
Protection Device ◽  
Complete Occlusion ◽  
Embolic Protection Device ◽  
Real Risk ◽  
Proximal Internal Carotid Artery ◽  
Protection Devices ◽  
Distal Protection ◽  
Occluded Segment

Abstract BACKGROUND: There is a theoretical concern that a thrombus may be dislodged distally when crossing the occluded segment during recanalization of a complete occlusion. OBJECTIVE: To assess the immediate postprocedural brain diffusion-weighted image (DWI) findings following endovascular recanalization using an embolic protection device for proximal internal carotid artery (ICA) occlusion. MATERIALS AND METHODS: We retrospectively identified 12 patients who underwent stent implantation for sudden symptomatic occlusion of the proximal ICA. In 8 patients, no additional intracranial occlusions were identified. In 4 patients, an additional intracerebral thrombus was detected in the middle cerebral artery. Distal protection devices were used in all cases. We evaluated the presence and amount of retrieved embolic fragments in the distal protection devices. The incidence and location of postprocedural emboli were determined using DWI. RESULTS: Recanalization of the proximal ICA was achieved in all patients. After complete occlusion of the proximal ICA was demonstrated, primary passage of the embolic protection device through the occluded ICA was gently navigated in 7 patients. However, this was not possible in 5 patients. Three patients developed new lesions on postprocedural DWI. Of the 12 patients in which distal protection devices were used, debris was detected in 7 patients. CONCLUSION: In endovascular revascularization of proximal ICA occlusion, postprocedural emboli occur less frequently than reported in a systematic review of the DWI literature. The real risk of dislodging thrombi appears to be from plaque fragment mobilization by angioplasty, rather than from crossing an occluded segment.

scholarly journals Modification of a Braided Support Catheter into a Rapid Exchange System for Navigation of a Distal Protection Device through Significant Vascular Tortuosity

2014 ◽  
Vol 20 (6) ◽  
pp. 663-668 ◽  
Author(s):  
Dale Ding ◽  
Robert M. Starke ◽  
Christopher R. Durst ◽  
Avery J. Evans
Keyword(s):  
Carotid Artery ◽  
Internal Carotid ◽  
Vascular Anatomy ◽  
Exchange System ◽  
Stenotic Lesion ◽  
Vascular Tortuosity ◽  
Rapid Exchange ◽  
Catheter System ◽  
Protection Devices ◽  
Distal Protection

Cerebral embolic protection devices (EPD) reduce the rate of periprocedural thromboembolic complications and are currently used in all carotid artery stenting (CAS) procedures. However, tortuous vascular anatomy of the internal carotid artery (ICA) may prevent navigation of distal EPDs, thereby leading to inadequate cerebral protection. We present a case in which significant tortuosity of the ICA distal to the stenotic lesion precluded navigation of currently available distal EPDs. During a CAS procedure, significant vascular tortuosity of the distal cervical ICA was noted which prevented navigation of currently available distal EPDs due to catheter kinking. In order to overcome this anatomic barrier, a novel rapid exchange catheter system (RECS) was created using a modified DAC 038 braided catheter through which a distal EPD and microguidewire were placed. This newly devised RECS allowed navigation of the distal EPD past the tortuous ICA bend and successful completion of the CAS procedure without periprocedural complications. We demonstrate that modification of currently available devices can, in select cases, effectively address cases of significant vascular tortuosity which limit the use of conventional distal EPDs.

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