Carotid Artery Stenting Using the Double Embolic Protection Technique

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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