Cerebral Protection during Carotid Angioplasty

Carotid angioplasty, until recently carried out in selected patients at a few specialist centres, is currently growing at a rate of 20% a year. The main limitation on its development to date was the risk of cerebral embolization demonstrated experimentally at each stage of the procedure. Rapid advances in materials, especially the introduction of cerebral protective devices, has opened the way to a rapid expansion in the use of this method thanks to a significant drop in complications during the method's learning curve. Current outcomes are increasingly close to those of traditional surgery. Carotid angioplasty is now a first choice treatment in patients at high risk or unsuitable for surgery. Angioplasty is also growing as an adjuvant rather than alternative treatment to surgery especially in patients presenting anatomical problems. Cerebral protection devices enhancing treatment outcome are not so much an option as a necessity in all these patients as confirmed by ongoing studies (CARESS, PACE, Italian SICVE register) assessing the efficacy of carotid angioplasty using cerebral protection devices. The final results of these studies should establish the best method of cerebral protection and confirm the role of carotid angioplasty in the treatment of carotid artery stenotic disease.

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In Vitro Comparison of Four Cerebral Protection Filters for Preventing Human Plaque Embolization during Carotid Interventions

Journal of Endovascular Therapy ◽

10.1177/152660280200900612 ◽

2002 ◽

Vol 9 (6) ◽

pp. 793-802 ◽

Cited By ~ 32

Author(s):

Stefan Müller-Hülsbeck ◽

Thomas Jahnke ◽

Carsten Liess ◽

Christoph Glass ◽

Friedrich Paulsen ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Bifurcation ◽

External Carotid Artery ◽

Cerebral Protection ◽

External Carotid ◽

Carotid Angioplasty ◽

Protection Device ◽

Fluid Medium ◽

Vitro Model

Purpose: To evaluate in an in vitro bench-top model the efficacy of 4 filtration devices designed for cerebral protection during carotid angioplasty. Methods: Embolization during carotid angioplasty was simulated with human plaque material (8 to 12 particles weighing 6.02 ± 0.10 mg) in an open flow model with the aortic arch and carotid bifurcation made from elastic silicone tubes and saline used as the fluid medium. The 500 to 1500-µm particles were injected into the internal carotid artery (ICA) in front of the test protection device, which was deployed 5 cm distal to the bifurcation. Particles getting past the protection device or flowing into the external carotid artery (ECA) were caught in 100-µm filters and weighed. Ten trials were made on each of 4 devices: Angioguard, FilterWire EX, TRAP, and NeuroShield. All were deployed according to the manufacturers' directions except the FilterWire, which was manually repositioned in all tests to eliminate a gap between the filter and the tube wall. Results: The lowest weight of missed particles in the effluent was obtained with the NeuroShield (0.05 ± 0.04 mg, 0.8% of injected particle weight) and FilterWire (0.08 ± 0.05 mg, 1.3%; p=0.254 compared to NeuroShield, p=0.006 versus TRAP). The weight of particles missed by the TRAP device (0.16 ± 0.06 mg, 2.6%; p<0.001 versus NeuroShield and Angioguard, p<0.05 compared to Filter Wire) was higher, and the largest amount of missed particles was observed with the Angioguard filter (0.27 ± 0.06 mg, 4.4%; p<0.001 compared to all). NeuroShield and FilterWire were significantly different (p<0.001) compared to Angioguard and TRAP in a pairwise analysis. No embolization into the ECA occurred. Conclusions: In vitro, none of the tested devices had the ability to completely prevent embolization into the ICA. Comparing current designs, the NeuroShield filter and the FilterWire EX captured the highest percentage of human particles in this in vitro model, probably due to their larger filter volume.

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