Transcervical Carotid Stenting with Flow Reversal for Neuroprotection: Technique, Results, Advantages, and Limitations

Vascular ◽  
2006 ◽  
Vol 14 (5) ◽  
pp. 245-255 ◽  
Author(s):  
Iraklis I. Pipinos ◽  
Matias Bruzoni ◽  
Jason M. Johanning ◽  
G. Matthew Longo ◽  
Thomas G. Lynch
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Carotid Bifurcation ◽  
Carotid Stenting ◽  
Flow Reversal ◽  
Transcervical Approach ◽  
Weighted Magnetic Resonance Imaging ◽  
Carotid Occlusive Disease ◽  
Angioplasty And Stenting ◽  
Carotid Angioplasty And Stenting

Carotid angioplasty and stenting are progressively earning a role as a less invasive alternative in the treatment of carotid occlusive disease. The most common approach for carotid artery stenting involves transfemoral access and use of a filter or balloon device for neuroprotection. This approach has limitations related to both the site of access and the method of neuroprotection. Specifically, an aortoiliac segment with advanced occlusive or aneurysmal disease or an anatomically unfavorable or atheromatous arch and arch branches can significantly limit the safety of the retrograde transfemoral pathway to the carotid bifurcation. Additionally, data provided by the use of transcranial Doppler monitoring and diffusion-weighted magnetic resonance imaging in patients undergoing filter- or balloon-protected carotid artery stenting demonstrate that currently available devices are associated with a considerable incidence of cerebral embolization. To address these limitations, we, along with others, have employed a direct transcervical approach for carotid artery stenting that incorporates the principle of flow reversal for neuroprotection. The technique bypasses all of the anatomic limitations of transfemoral access and simplifies the application of flow reversal, which is one of the safest neuroprotection techniques. The purpose of this review is to describe our method of transcervical carotid artery stenting, review the accumulating outcomes data, and discuss the clinical advantages of and indications for this increasingly popular technique.

scholarly journals TRANSRADIAL AND TRANSFEMORAL ACCESS FOR CAROTID ARTERY STENTING WITH AN EMPHASIS ON THE DETECTION OF MICROEMBOLIZATION WITH DIFFUSION WEIGHTED MAGNETIC RESONANCE IMAGING (TACTILE TRIAL).

2018 ◽  
Vol 7 (3) ◽  
pp. 83-93
Author(s):  
D. U. Malaev ◽  
E. I. Kretov ◽  
V. I. Baystrukov ◽  
R. A. Naidenov ◽  
A. A. Prokhorikhin ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Carotid Artery ◽  
Primary Endpoint ◽  
Carotid Artery Stenting ◽  
Carotid Stenting ◽  
Resonance Imaging ◽  
Diffusion Weighted ◽  
Weighted Magnetic Resonance Imaging ◽  
Procedural Success

Aim. To compare transradial (TR) and transfemoral (TF) approach for carotid artery stenting (CAS) with an emphasis on the detection of micro-embolization with diffusion-weighted magnetic resonance imaging (DW-MRI).Methods. 96 patients were included in the study in the period from January 2015 to October 2017 with further randomized 1 : 1 to the TR and TF groups. The inclusion criteria were the following: symptomatic stenosis ICA >70%; or asymptomatic stenosis ICA >80%. The positive history of stroke, myocardial infarction or open heart surgery <1 month were the exclusion criteria for the study. The primary endpoint was the incidence of new cerebral ischemic lesions as assessed by DW-MRI. All CAS procedures were performed by two experienced operators according to the approved protocol.Results. Procedural success with TR approach was 46 (96%) versus 48 (100%) with TF approach (p = 0.495). Crossover rate was 4% in the TR group. The rate of primary endpoint in the TR and TF groups was 50 and 52%, respectively. The absolute risk difference was -2% (95% CI [-0.21, 0.17], p (non-inferiority) = 0.03). An «on-treatment» analysis revealed a tendency towards a reduced microembolic foci when intervening on the right ICA via TR approach compared to TF (44% vs. 68%, p = 0.478), and a reverse trend when intervening on the left ICA via TR compared to TF approach (57% versus 36%, respectively, p = 0.437).Conclusion. Carotid stenting via transradial approach is noninferior for cerebral embolism to transfemoral approach. The rates of MACCE and vascular complications were similar in both groups. There was no significant difference in the procedural success rate in the transfemoral and transradial groups. The fluoroscopy time during transradial carotid stenting was higher in comparison with transfemoral carotid stenting, though the procedure duration was similar in both groups.

Transcervical Approach With Protective Flow Reversal for Carotid Angioplasty and Stenting

2005 ◽  
Vol 12 (4) ◽  
pp. 446-453 ◽  
Author(s):  
Iraklis I. Pipinos ◽  
Jason M. Johanning ◽  
Chinh N. Pham ◽  
Krishnasamy Soundararajan ◽  
Thomas G. Lynch
Keyword(s):  
Flow Reversal ◽  
Carotid Angioplasty ◽  
Transcervical Approach ◽  
Angioplasty And Stenting ◽  
Carotid Angioplasty And Stenting

scholarly journals Achievable aspiration flow rates with large balloon guide catheters during carotid artery stenting

2020 ◽  
Vol 3 (1) ◽  
Author(s):  
Tilman Schubert ◽  
Leonardo Rivera-Rivera ◽  
Alejandro Roldan-Alzate ◽  
Daniel Consigny ◽  
Lorenz Leitner ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Carotid Stenting ◽  
Balloon Occlusion ◽  
Flow Reversal ◽  
Maximum Diameter ◽  
External Carotid ◽  
4D Flow ◽  
Flow Rates ◽  
Guide Catheter

Abstract Background Emergency carotid artery stenting (CAS) is a frequent endovascular procedure, especially in combination with intracranial thrombectomy. Balloon guide catheters are frequently used in these procedures. Our aim was to determine if mechanical aspiration through the working lumen of a balloon occlusion catheter during the steps of a carotid stenting procedure achieve flow rates that may lead to internal carotid artery (ICA) flow reversal which consecutively may prevent distal embolism. Methods Aspiration experiments were conducted using a commercially available aspiration pump. Aspiration flow rates/min with 6 different types of carotid stents inserted into a balloon guide catheter were measured. Measurements were repeated three times with increasing pressure in the phantom. To determine if the achieved aspiration flow rates were similar to physiologic values, flow rates in the ICA and external carotid artery (ECA) in 10 healthy volunteers were measured using 4D-flow MRI. Results Aspiration flow rates ranged from 25 to 82 mL/min depending on the stent model. The pressure in the phantom had a significant influence on the aspiration volume. Mean blood flow volumes in volunteers were 210 mL/min in the ICA and 101 mL/min in the ECA. Conclusions Based on the results of this study, flow reversal in the ICA during common carotid artery occlusion is most likely achieved with the smallest diameter stent sheath and the stent model with the shortest outer stent sheath maximum diameter. This implies that embolic protection during emergency CAS through aspiration is most effective with these models.

Technique and clinical evidence of neuroprotection in carotid artery stenting

VASA ◽  
2014 ◽  
Vol 43 (2) ◽  
pp. 100-112 ◽  
Author(s):  
Rainer Knur
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Clinical Evidence ◽  
Carotid Artery Disease ◽  
Balloon Occlusion ◽  
Protection Devices ◽  
Artery Disease ◽  
Distal Filter ◽  
Angioplasty And Stenting ◽  
Carotid Angioplasty And Stenting

Carotid artery stenting has been advocated as an effective alternative to carotid endarterectomy. Periprocedural embolization of debris during endovascular treatment of carotid artery disease may result in neurological deficit. Different strategies are being developed and evaluated for their ability to minimize the clinical embolic risk. Distal filter devices, proximal and distal balloon occlusion systems are increasingly used in carotid artery stenting, because they seem to be safe and effective in preventing distal embolization, according to several uncontrolled studies. However the use of embolic protection devices is a subject of controversy and no data on their benefit are available from randomized controlled multi-center trials. The technique and clinical evidence of cerebral protection systems during carotid angioplasty and stenting for stroke prevention are reviewed.

scholarly journals Carotid Stenting without Angioplasty

2002 ◽  
Vol 29 (2) ◽  
pp. 175-179 ◽  
Author(s):  
S. Men ◽  
S.P. Lownie ◽  
D.M. Pelz
Keyword(s):  
Balloon Angioplasty ◽  
Plain Film ◽  
Carotid Bifurcation ◽  
Carotid Stenting ◽  
Vessel Diameter ◽  
Moderate Increase ◽  
Atherosclerotic Stenosis ◽  
Hemodynamic Improvement ◽  
Angioplasty And Stenting ◽  
Carotid Angioplasty And Stenting

Abstract:Background:Carotid angioplasty and stenting is gaining popularity as an alternative to carotid endarterectomy for the treatment of carotid bifurcation stenosis. The major concern with the procedure is the risk of embolic stroke which may be initiated by balloon angioplasty of friable atherosclerotic plaque. Elimination of angioplasty may result in a lower incidence of embolic complications.Method:We describe a case in which a self-expanding stent alone, without balloon angioplasty, was used to successfully dilate an atherosclerotic stenosis of the carotid bifurcation.Results:A moderate increase in vessel diameter, from 75% to 50%, was immediately observed after stent placement alone. No embolic complications were observed and follow-up plain film and ultrasound examinations showed progressive stent enlargement with excellent anatomic and hemodynamic results.Conclusions:In this case of severe carotid stenosis, the use of a self-expanding stent alone, without balloon angioplasty, resulted in excellent anatomic and hemodynamic improvement.

scholarly journals Postmortem Pathological Examination of a Case One Month after Carotid Artery Stenting

2000 ◽  
Vol 6 (1_suppl) ◽  
pp. 171-174
Author(s):  
Y. Otsuka ◽  
R. Waki ◽  
C. Yutani ◽  
H. Ishibashi-Ueda ◽  
T. Onodera ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Carotid Bifurcation ◽  
Carotid Stenting ◽  
Pathological Process ◽  
Coronary Stenting ◽  
Pathological Examination ◽  
Eccentric Compression ◽  
Human Carotid

There have been few pathological reports on human carotid stenting. A 73-year-old diabetic male with 80% stenosis in the left carotid bifurcation. Despite no neurological events, he died of pneumonia one month after. Findings pathological examination revealed: successful dilatation without deformity of the stent, eccentric compression and partial disruption of the plaque by struts, thrombi around disrupted plaque, and neointimal growth. Findings were generally compatible with those reported on coronary stenting. Case accumulation is required to clarify an exact pathological process and establish a procedure to reduce complications.

Endovascular Advances for Extracranial Carotid Stenosis

Neurosurgery ◽  
2014 ◽  
Vol 74 (suppl_1) ◽  
pp. S92-S101 ◽  
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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