Microembolization during carotid artery stenting in patients with high-risk, lipid-rich plaque. A randomized trial of proximal versus distal cerebral protection

Randomized clinical trial comparing neurological outcomes after carotid endarterectomy or stenting

Background

Silent infarction in the brain can be detected in around 34 per cent of patients after carotid endarterectomy (CEA) and 54 per cent after carotid angioplasty and stenting (CAS). This study compared the risk of new infarctions in the brain in patients undergoing CEA or CAS.

Methods

Consecutive patients with internal carotid artery (ICA) stenosis exceeding 70 per cent were screened for inclusion in this prospective study. Patients with indications for intervention, and eligible for both methods, were allocated randomly to CEA or CAS. Neurological examination, cognitive function tests and MRI of the brain were undertaken before and 24 h after intervention.

Results

Of 150 randomized patients, 73 (47 men; mean age 64·9(7·1) years) underwent CEA and 77 (58 men; 66·4(7·5) years) had CAS. New infarctions on MRI were found more frequently after CAS (49 versus 25 per cent; P = 0·002). Lesion volume was also significantly greater after CAS (P = 0·010). Multiple logistic regression analyses identified intervention in the right ICA as the only independent predictor of brain infarction (odds ratio 2·10, 95 per cent c.i. 1·03 to 4·25; P = 0·040). Stroke or transient ischaemic attack occurred in one patient after CEA and in two after CAS. No significant differences were found in cognitive test results between the groups.

Conclusion

These data confirm a higher risk of silent infarction in the brain on MRI after CAS in comparison with CEA, but without measurable change in cognitive function. Registration number: NCT01591005 (http://www.clinicaltrials.gov).

Carotid artery stenting

Carotid artery stenting (CAS) has achieved clinical equipoise with carotid endarterectomy (CEA), as evidenced by 2 large U.S. randomized clinical trials, multiple pivotal registry trials, and 2 multispecialty guideline documents endorsed by 14 professional societies. The largest randomized trial conducted in patients at average surgical risk of CEA, CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) found no difference between CAS and CEA for the combined endpoint of stroke, death, and myocardial infarction (MI) after 4 years of follow-up. The largest randomized trial comparing CAS and CEA in patients at increased surgical risk, SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy), looked at 1-year stroke, death, and MI incidence and found no difference in symptomatic patients, but a significantly better outcome in asymptomatic patients for CAS (9.9% vs. 21.5%; p = 0.02). Given that >70% of carotid revascularization procedures are performed in asymptomatic patients for primary prevention of stroke, it is incumbent upon clinicians to demonstrate that revascularization has an incremental benefit over highly effective modern medical therapy alone.

Carotid artery stenting: current and emerging options

Carotid artery stenting technologies are rapidly evolving. Options for endovascular surgeons and interventionists who treat occlusive carotid disease continue to expand. We here present an update and overview of carotid stenting devices. Evidence supporting carotid stenting includes randomized controlled trials that compare endovascular stenting to open surgical endarterectomy. Carotid technologies addressed include the carotid stents themselves as well as adjunct neuroprotective devices. Aspects of stent technology include bare-metal versus covered stents, stent tapering, and free-cell area. Drug-eluting and cutting balloon indications are described. Embolization protection options and new direct carotid access strategies are reviewed. Adjunct technologies, such as intravascular ultrasound imaging and risk stratification algorithms, are discussed. Bare-metal and covered stents provide unique advantages and disadvantages. Stent tapering may allow for a more fitted contour to the caliber decrement between the common carotid and internal carotid arteries but also introduces new technical challenges. Studies regarding free-cell area are conflicting with respect to benefits and associated risk; clinical relevance of associated adverse effects associated with either type is unclear. Embolization protection strategies include distal filter protection and flow reversal. Though flow reversal was initially met with some skepticism, it has gained wider acceptance and may provide the advantage of not crossing the carotid lesion before protection is established. New direct carotid access techniques address difficult anatomy and incorporate sophisticated flow-reversal embolization protection techniques. Carotid stenting is a new and exciting field with rapidly advancing technologies. Embolization protection, low-risk deployment, and lesion assessment and stratification are active areas of research. Ample room remains for further innovations and developments.

Endovascular Management of Brachiocephalic Disease

Brachiocephalic disease can pose important clinical risks and manifestations. Most of these lesions are amenable to endovascular treatment. However, these treatments have significant risks and require modified procedural techniques. All interventions require a careful preprocedural evaluation and consultation. These endovascular interventions should be performed by experienced operators with extensive previous carotid and endovascular experience in appropriate adequately equipped venues. Most brachiocephalic disease also has surgical options for treatment. This article presents guidelines to assist experienced operators to perform these procedures with proper technique after using good clinical judgment.

Cerebral microemboli and neurocognitive change after carotid artery stenting with different embolic protection devices

OBJECTIVES

Proximal cerebral protection devices have been developed as an alternative to filter protection devices for reducing neurological complications during carotid artery stenting (CAS). The aim of the present study was to evaluate the frequency of silent cerebral embolism after CAS using different cerebral embolic protection devices and the impact of silent cerebral embolism on neurocognitive function.

METHODS

One hundred consecutive patients who underwent CAS were enrolled. The patients were randomized to either proximal balloon occlusion or filter protection. Neurocognitive tests were performed before and six months after CAS. Cerebral embolisms were evaluated with diffusion-weighted magnetic resonance imaging (DW-MRI).

RESULTS

The number and volume of new ischemic lesions found with DW-MRI were higher in the filter protection group than in the proximal balloon occlusion group. According to our definition, nine (21%) patients in the balloon occlusion group and 16 (36%) patients in the filter protection group showed neurocognitive decline, and ten (23%) patients in the balloon occlusion group and four (9%) patients in the filter protection group showed neurocognitive improvement (NS). Regarding the group of patients with new cerebral ischemic lesions on DW-MRI, neurocognitive decline occurred in 14 (31%) of 45 patients with DW-MRI lesions and 11 (26%) of 43 patients without DW-MRI lesions (NS).

CONCLUSION

Neurocognitive outcome after CAS is unpredictable; both neurocognitive decline and improvement can occur. In this study, the proximal balloon occlusion system significantly decreased cerebral microemboli during CAS compared to filter protection. Cerebral microembolism was not found to be associated with neurocognitive decline.

Cerebral embolic lesions detected with diffusion-weighted magnetic resonance imaging following carotid artery stenting: a meta-analysis of 8 studies comparing filter cerebral protection and proximal balloon occlusion

OBJECTIVES

The aim of this meta-analysis was to evaluate and compare the efficacy of the 2 different neuroprotection systems in preventing embolization during carotid artery stenting (CAS), as detected by diffusion-weighted magnetic resonance imaging (DW-MRI).

BACKGROUND

Data from randomized and nonrandomized studies comparing both types of embolic protection devices revealed contrasting evidence about their efficacy in neuroprotection, as assessed by the incidence of new ischemic lesions detected by DW-MRI.

METHODS

Eight studies, enrolling 357 patients, were included in the meta-analysis. Our study analyzed the incidence of new ischemic lesions/patient, comparing filter cerebral protection and proximal balloon occlusion.

RESULTS

Following CAS, the incidence of new ischemic lesions/patient detected by DW-MRI was significantly lower in the proximal balloon occlusion group (effect size [ES]: -0.43; 95% confidence interval [CI]: -0.84 to -0.02, I(2) = 70.08, Q = 23.40). Furthermore, following CAS, the incidence of lesions at the contralateral site was significantly lower in the proximal protection group (ES: -0.50; 95% CI: -0.72 to -0.27, I(2) = 0.00, Q = 3.80).

CONCLUSIONS

Our meta-analysis supports the concept that the use of proximal balloon occlusion compared with filter cerebral protection is associated with a reduction of the amount of CAS-related brain embolization. The data should be confirmed by a randomized clinical trial.

Endarterectomy or carotid artery stenting: the quest continues part two

BACKGROUND

Although randomized trials on carotid artery stenting (CAS) could not establish its equivalence to carotid endarterectomy (CEA) in patients with symptomatic carotid disease, CAS is rapidly evolving. Data on long-term outcome after CAS from randomized trials have now become available and ongoing, prospectively held registries frequently publish their results in increasing numbers of patients. We have therefore reviewed the currently available literature and provide an update of our previous article on this topic.

DATA SOURCES

PubMed literature searches were performed to identify relevant studies regarding current status of CEA and stenting for symptomatic carotid stenosis.

CONCLUSIONS

The efficacy of CAS in patients with symptomatic carotid artery stenosis remains unclear because of varying results in randomized trials. Although multiple registries do report promising results after CAS, peri-interventional stroke/death rates still exceed those rates currently found after CEA. Therefore, CEA remains the "gold standard" in treating these patients.

Neural damage biomarkers during open carotid surgery versus endovascular approach

BACKGROUND

Carotid endarterectomy (CEA) is the gold standard for treating severe carotid artery stenosis, whereas carotid artery stenting (CAS) represents an endovascular alternative. The objective of this study was to assess the potential neural damage following open or endovascular carotid surgery measured by peripheral blood concentration of 3 biomarkers: S100β, matrix metalloproteinase-9 (MMP-9), and d-dimer.

METHODS

Data for this prospective investigation were obtained from the Carotid Markers study (January 2010-2011), which sought to measure the levels of specific biomarkers of neuronal damage and thrombosis on candidates to CEA or CAS presenting at the Department of Vascular Surgery of the Nuovo Ospedale S. Agostino Estense of Modena (Italy) at baseline and at 24 hr after surgery. Relevant medical comorbidities were noted.

RESULTS

A total of 113 consecutive patients were enrolled in the study, 41 in the endarterectomy group and 72 in the endovascular group. The baseline levels of the studied biomarkers did not show any statistically significant difference between the groups with the exception of MMP-9, which showed higher concentrations in the endovascular group (median 731 vs. 401, P = 0.0007), while 24 hr after surgery the endarterectomy group featured significantly higher peripheral blood concentrations of MMP-9, S100β, and d-dimer. Conversely, no significant difference was detected in the endovascular group except the d-dimer level.

CONCLUSIONS

Neural damage biomarkers demonstrated a substantial difference between open and endovascular carotid surgery, which, if performed in selected patients, may become a less invasive alternative to CEA.

State of the art in carotid artery stenting: trial data, technical aspects, and limitations

The volume of carotid artery stenting (CAS) safety and efficacy data has grown exponentially over the last decade. Recent comparative data with carotid endarterectomy, the utility of embolic protection devices, peri-procedural medications, basic technical aspects of CAS, developments in carotid stent design, potential complications of CAS, and complication risk factors are discussed in this review.

Endovascular Advances for Extracranial Carotid Stenosis

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.

Complications and Solutions with Carotid Stenting

Complications of carotid stenting can be classified as neurologic, cardiovascular, death, carotid, access site, device malfunctions, and general and late complications. The risk of most complications is related to readily identifiable patient and anatomic factors. Management and outcome of complications require immediate recognition and a team-based approach to patient care.

Skin to Skin: Transfemoral Carotid Angiography and Stenting

Carotid artery stenting (CAS) has emerged as an attractive alternative to carotid endarterectomy (CEA) for the treatment of carotid artery disease. Several recent trials demonstrate excellent and improving results, even at high risk in CEA patients. Randomized North American trials suggest equivalence of CAS to CEA in high-risk and standard-risk patients. However, these improved CAS results apply only to CAS procedures performed by experienced operators at experienced centers. Furthermore, these improved results are due largely to operators' lessons learned, helping with appropriate case selection.

Skin to Skin: Transradial Carotid Angiography and Stenting

Carotid artery stenting (CAS) is a proven alternative to carotid endarterectomy in patients with significant carotid disease. The femoral artery is the conventional access site for CAS procedures. However, this approach may be problematic because of peripheral vascular disease and anatomic variations. Access site complications are the most common adverse event after CAS from the transfemoral approach (TFA) and most technical failures are related to a complex aortic arch. The transradial approach has been evaluated to address the shortcomings of TFA. In cases involving a complex arch, transradial access may be a viable alternative strategy.

Surgery Versus Stenting in Symptomatic Patients

Symptomatic carotid artery stenosis is an important cause of stroke with significant morbidity and mortality. Revascularization with carotid endarterectomy reduces the recurrence of stroke and until recently was considered the gold standard of therapy. Carotid artery stenting has emerged as an alternative method of revascularization in both high-risk and standard-risk patients. This review appraises the role of surgery versus stenting for patients with symptomatic carotid stenosis.

Patient, Anatomic, and Procedural Characteristics That Increase the Risk of Carotid Interventions

Subjective characteristics for increased risk of carotid artery stenting (CAS) have included thrombus-containing lesions, heavily calcified lesions, very tortuous vessels, and near occlusions. More objective high-risk features include contraindications to dual antiplatelet therapy, a history of bleeding complications, and lack of femoral artery vascular access. Variables that increase the risk of CAS complications are attributed to patient characteristics, anatomic features, or procedural factors. Operator and hospital volume affect the risk of complications occurring with CAS. As the complexity and difficulty of CAS patients increases, the need for more highly skilled operators and teams becomes even more necessary to minimize complications.

Carotid artery stenting - current status of the procedure

Surgical carotid endarterectomy (CEA) was long considered the standard approach for the treatment of atherosclerotic carotid artery disease. This was based on results of several randomized trials demonstrating its effectiveness over the best medical therapy. In the past two decades, patients identified high-risk for surgery were offered carotid artery stenting (CAS) as a less invasive option. Despite its initial limitations, CAS has evolved into an elaborate method currently considered to be equivalent and in selected patients even preferable to CEA. However, outcomes of both procedures are highly operator dependent and a simple stratifying method to prioritize CAS, CEA or medical therapy only has not yet been proposed. In addition, recently published randomized trials highlighted the importance of proper patient selection and rigorous training contributing to low absolute rates of (procedural) adverse events. This review discusses the history and evidence for carotid revascularization and briefly presents technical aspects and innovations in CAS.

Combination of flow reversal and distal filter for cerebral protection during carotid artery stenting

BACKGROUND

Carotid artery stenting (CAS) with distal filter protection allows continuous cerebral perfusion, although it is associated with a greater risk of cerebral ischemic complications than other protection systems. To reduce cerebral ischemic complications, CAS was performed under combined cerebral protection using both flow reversal (FR) and a distal filter.

METHODS

Fifty-six stenoses of 52 patients were treated with CAS using the combined protection of FR and a distal filter, with intermittent occlusion of both the common carotid artery (CCA) and the external carotid artery. The blood flow was reversed into the guiding catheter to the central venous system via an external filter, which collected the debris. Clinical outcomes, the rates of capturing visible debris, and new ischemic signals on diffusion-weighted magnetic resonance imaging (DWI-MRI) were evaluated.

RESULTS

The overall technical success rate was 92.9% (52/56). Successful stent deployment was achieved in 100% (56/56) of the cases. No procedural-related emboli causing a neurologic deficit were observed. In 38.5% (20/52) of the cases, visible debris were captured by only the external filter, and in 17.3% (9/52), visible debris were captured by both external and distal filters. In no case was visible debris noted in only the distal filter. New ischemic signals on DWI-MRI were detected in 9.6% (5/52). The 30-day myocardial infarction, stroke, and death rates were 0%.

CONCLUSIONS

The additional use of a distal filter captures emboli in 17.3% of cases, and because the occlusion is only intermittent, the procedure is potentially applicable even in those who cannot tolerate prolonged balloon occlusion of the CCA.

Proximal versus distal protection during carotid artery stenting: analysis of the two treatment approaches and associated clinical outcomes

OBJECTIVE

Cerebral protection device utilization during carotid artery stenting (CAS) has been shown to decrease risk of perioperative stroke. The two most commonly used devices are distal filters and proximal protection devices, which allow blood flow cessation or flow reversal. The goal of the present study was to examine anatomic and morphologic characteristics of the treated lesions using each type of cerebral protection device and compare clinical 30-day adverse event rates between the two cerebral protection groups.

METHODS

We conducted a single-center, retrospective review of consecutive CAS cases with proximal protection devices that were matched with CAS cases using distal filter protection devices based on indication (symptomatic vs. asymptomatic), age, and gender. We reviewed clinical, anatomic, and morphologic characteristics of the stented lesions in cases of proximal or distal protection and also studied the rate of major adverse events within the first 30 days after the procedure.

RESULTS

We identified a total of 70 patients treated with proximal protection devices who were matched in a blinded fashion to 70 cases with distal protection. There was a significantly higher number of high-risk lesions in patients who had CAS using proximal protection devices (P = 0.009). There was no significant difference in overall frequency of 30-day adverse outcomes (transient ischemic attack/stroke/reperfusion hemorrhage/death) between the two groups (P = 1.0).

CONCLUSIONS

Our study is the first attempt (to our knowledge) to review and compare anatomic and morphologic characteristics of the stented lesions in cases of proximal versus distal protection for CAS. Our data indicate that in properly selected patients both approaches could be equally safe and effective.

Flow reversal versus filter protection: a pilot carotid artery stenting randomized trial

BACKGROUND

Carotid artery stenting (CAS) has become an alternative treatment for patients presenting symptomatic carotid artery stenosis. The improvement in clinical outcomes with CAS has been associated with the development of embolic protection devices. The trial aim is to compare flow reversal versus filter protection during CAS through femoral access.

METHODS AND RESULTS

Patients were randomly enrolled in CAS using flow reversal or filter protection. The primary end points were the incidence, number, and size of new ischemic brain lesions after CAS. The secondary end points included major adverse cardiac and cerebrovascular events, transient ischemic attack, and definitive ischemic brain lesions on fluid-attenuated inversion recovery magnetic resonance image at a 3-month follow-up. Ischemic brain lesions were assessed by a 3T magnetic resonance image. Neurological outcomes were evaluated by means of the National Institutes of Health Stroke Scale and the modified Rankin Scale (mRS). Forty consecutive patients were randomly assigned. Compared with flow reversal (n=21), filter protection (n=19) resulted in a significant reduction in the incidence (15.8% versus 47.6%, P=0.03), number (0.73 versus 2.6, P=0.05), and size (0.81 versus 2.23 mm, P=0.05) of new ischemic brain lesions. Two patients, 1 from each group, presented transient ischemic attack at 3-month follow-up. There were no major adverse cardiac and cerebrovascular events in the hospital or at 3-month follow-up.

CONCLUSIONS

In this small sample size trial, filter protection was more effective than flow reversal in reducing ischemic brain lesions during CAS through femoral approach.

CLINICAL TRIAL REGISTRATION URL

http://portal2.saude.gov.br/sisnep/. Unique identifier: 0538.0.004.000-10.

[Carotid artery stenting technique]

Over the past 25 years carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA). Most of all younger patients and symptomatic patients with contralateral carotid artery occlusion particularly benefit from CAS. To achieve an optimal result with CAS, patient selection and even more important, knowledge and experience of the interventionist is crucial. The periprocedural complication rate of CAS in large experienced centers is lower (2-3%) than those in randomized trials. Several different devices are now available which allow the procedure to be tailored according to patient anatomy and lesion complexity. Complications like hyperperfusion syndrome and intracerebral bleeding, rupture of side branches of the external or internal carotid artery as well as problems caused by slow flow can be widely avoided by adequate experience.

Comparison of anti-embolic protection with proximal balloon occlusion and filter devices during carotid artery stenting: clinical and procedural outcomes

AIM

The objective of this study was to compare the periprocedural and clinical outcomes after carotid artery stenting (CAS) with proximal protection devices versus with distal protection devices.

MATERIAL AND METHODS

Patients with internal carotid artery (ICA) stenosis undergoing CAS with cerebral embolic protection were randomly assigned to proximal balloon occlusion or distal filter protection. Adverse events were defined as death, major stroke, minor stroke, transient ischemic attack (TIA) and myocardial infarction (MI). Periprocedural and 30-day adverse events and ICA vasospasm rates were compared between the two embolic protection groups.

RESULTS

Eighty-eight consecutive patients were randomized: 48 patients with proximal protection (mean age 68.8 ±13.6, 66% male) and 40 patients with a distal protection device (mean age 65.4 ±12.3; 70% male). There was no significant difference in periprocedural or 30-day adverse event rates between the two groups (p > 0.05). However, there was a higher periprocedural ICA vasospasm rate in the distal filter protection group (9 patients, 23%) compared with the proximal balloon occlusion group (1 patient, 2%) (p = 0.019).

CONCLUSIONS

There was no difference between the clinical periprocedural and 30-day adverse event rates of distal filter and proximal balloon protection systems. However, distal filter protection systems showed higher rates of periprocedural ICA vasospasm.

Carotid artery stenting: patient, lesion, and procedural characteristics that increase procedural complications

From the earliest experiences with carotid artery stenting (CAS) presumptive high risk features have included thrombus-containing lesions, heavily calcified lesions, very tortuous vessels, and near occlusions. In addition patients have been routinely excluded from CAS trials if they have contra-indications to dual antiplatelet therapy (aspirin and thienopyridines), a history of bleeding complications and severe peripheral arterial disease (PAD) making femoral artery vascular access difficult. Variables that increase the risk of CAS complications can be attributed to patient characteristics, anatomic or lesion features, and procedural factors. Clinical features such as older age (≥80 years), decreased cerebral reserve (dementia, multiple prior strokes, or intracranial microangiopathy) and angiographic characteristics such as excessive tortuosity (more than two 90° bends within 5 cm of the target lesion) and heavy calcification (concentric calcification ≥ 3 mm in width) have been associated with increased CAS complications. Other high risk CAS features include those that prolong catheter or guide wire manipulation in the aortic arch, make crossing a carotid stenosis more difficult, decrease the likelihood of successful deployment or retrieval of an embolic protection device (EPD), or make stent delivery or placement more difficult. Procedure volume for the operator and the catheterization laboratory team are critical elements in reducing the risk of the procedure. In this article, we help CAS operators better understand procedure risk to allow more intelligent case selection, further improving the outcomes of this emerging procedure.

Comparison between proximal versus distal protection devices in 287 cases of carotid revascularization using angioplasty and stenting: periprocedure complications, morbidity, and mortality

BACKGROUND

Embolic protection devices may decrease periprocedural thromboembolic complications during carotid angioplasty and stenting (CAS). When using proximal-protection devices (PPDs), protection starts before crossing the lesion. However, in the medical literature, its use is scarcely reported compared with that of distal-protection filters (DPDs). The objective of this study was to compare periprocedure complications, morbidity, and mortality among 287 consecutive cases of CAS performed with PPDs or DPDs.

PATIENTS AND METHODS

This was a retrospective analysis of 287 patients treated with CAS at our hospital between January 2006 and March 2012. Periprocedure complications, morbidity, and mortality at 30 days, including ischemic stroke or transient ischemic attack, reperfusion syndrome, myocardial infarction (MI), and death, were globally registered, and the results in PPD and DPD groups were compared.

RESULTS

Two hundred eight patients were treated with DPD and 79 with PPD; 80.8 % were symptomatic. CAS procedures performed with PPD presented a statistically significant greater grade of stenosis than those with DPD (82.5 vs. 74.5 %, p < 0.001). Death rates were 1.9 and 1.3 %; stroke rates were 4.3 and 3.8 %; MI rates were 1.4 and 1.3 %; and total morbidity and mortality rates were 6.2 and 5 % (DPD and PPD groups, respectively); all differences were nonstatistically significant. No statistical difference was found between symptomatic and asymptomatic patients.

CONCLUSION

Carotid angioplasty and stenting is a safe procedure to treat carotid disease in our patients. PPDs are not always associated with a greater risk of periprocedure complications, morbidity, and mortality than DPDs despite the greater grade of carotid stenosis in the PPD group. This observation may be of interest in the design of future studies with CAS.

Surgical dissection of the internal carotid artery under flow control by proximal vessel clamping reduces embolic infarcts during carotid endarterectomy

OBJECTIVE

To evaluate the efficacy of flow control of the internal carotid artery (ICA) by the clamping of the common carotid artery, external carotid artery, and superior thyroid artery during surgical ICA dissection to reduce ischemic complications after carotid endarterectomy (CEA).

METHODS

Sixty-seven patients (59 men; age, 70.5 ± 6.2 years) who underwent CEA by the same surgeon were retrospectively studied. Both conventional CEA (n = 29) and flow-control CEA (n = 38) were performed with the patient under general anesthesia and with the use of somatosensory-evoked potential and near-infrared spectroscopy monitoring as a guide for selective shunting. The number of new postoperative infarcts was assessed with preoperative and postoperative diffusion-weighted images (DWIs) obtained within 3 days of surgery. In addition to surgical technique, the effects of the following factors on new infarcts also were examined: age, side of ICA stenosis, high-grade stenosis, symptoms, and application of shunting.

RESULTS

New postoperative DWI lesions were observed in 7 of 67 patients (10.4%), and none of them was symptomatic. With respect to operative technique, the incidence rate of DWI spots was significantly lower in the flow-control group (2.6%) than in the conventional group (20.7%), odds ratio: 0.069; 95% confidence interval: 0.006-0.779; P = 0.031). On multiple logistic regression analysis, age, side of ICA stenosis, high-grade stenosis, symptoms, and the use of internal shunting did not have significant effects on new postoperative DWI lesions, whereas technique did have an effect.

CONCLUSION

The proximal flow-control technique for CEA helps avoid embolic complications during surgical ICA dissection.

Endovascular intervention for acute cervical carotid artery occlusion

BACKGROUND

Acute cervical carotid artery occlusion presents with a severe neurological deficit and is associated with unfavorable outcomes. In this study, the authors report their experience with patients having had acute ischemic stroke due to cervical carotid occlusion, who underwent endovascular intervention.

METHOD

Sixteen acute cervical carotid occlusion patients (15 males and 1 female; mean age 67.7 years) were treated by endovascularly between January 2009 and November 2012. Clinical, procedural, and angiographic data were retrospectively evaluated. Successful intracranial recanalization was based on thrombolysis in cerebral infarction score of 2B-3. A favorable outcome was defined as a modified Rankin Scale score of 0-2 at 90 days.

FINDINGS

The average score of National Institutes of Health Stroke Scale before treatment was 15.9. Ten of 16 patients (63 %) were associated with intracranial tandem occlusion. Ten (63 %) cases were caused by atherosclerotic, 4 (25 %) by atrial fibrillation (AF), and 2 (13 %) by dissection. Thirteen of 16 (81 %) achieved successful cervical recanalization and 7 of 16 (44 %) patients obtained sufficient cervical and intracranial perfusion. As a result, 5 of 16 (31 %) patients demonstrated favorable outcomes. Five of seven patients (71 %) with successful cervical and intracranial recanalization presented favorable outcomes. In contrast, none of the patients without cervical or intracranial recanalization presented favorable outcomes. Three of 6 (50 %) patients initially without intracranial occlusion showed favorable outcomes, but only 2 of 10 (20 %) patients associated with intracranial occlusion had favorable outcomes. On the aspect of etiology, in atherosclerotic cases, 4 of 10 (40 %) showed favorable outcomes. However, all four AF cases deteriorated into poor outcomes.

CONCLUSIONS

This study demonstrated the feasibility of endovascular intervention for acute cervical carotid artery occlusion. Although treatment for tandem occlusion and AF cases is an issue that should be resolved, intervention must be encouraged. Successful cervical and intracranial revascularization will be essential for favorable outcomes.

Ascertainment of any and all neurologic and myocardial damage in carotid revascularization: the key to optimization?

The majority of carotid revascularization procedures performed at present are in asymptomatic patients. Since such procedures convey no immediate benefit, but rather protect from future hazard, optimization of procedural safety is mandatory. The authors focus their discussion on the methodologies that assess periprocedural myocardial damage and brain injury, as used in past clinical trials, from the fields of perioperative medicine and neurovascular imaging, and discuss methodologies to reduce both events in carotid revascularization.

Strategies of clopidogrel load and atorvastatin reload to prevent ischemic cerebral events in patients undergoing protected carotid stenting. Results of the randomized ARMYDA-9 CAROTID (Clopidogrel and Atorvastatin Treatment During Carotid Artery Stenting) study

OBJECTIVES

This study sought to evaluate whether a strategy with a 600-mg clopidogrel load and a short-term, high-dose atorvastatin reload would improve outcomes in clopidogrel-naïve, statin-treated patients undergoing protected carotid stenting.

BACKGROUND

Optimal clopidogrel loading dose during carotid stenting has not been investigated; in addition, statin neuroprotection in this setting has not been described.

METHODS

A total of 156 patients were randomized using a 2 × 2 factorial design to receive either a 600-mg (n = 78) or 300-mg (n = 78) clopidogrel load given 6 h before intervention and either a atorvastatin reload (n = 76; 80 mg + 40 mg initiating 12 h before the procedure) or no statin reload (n = 80). The primary endpoint was the 30-day incidence of transient ischemic attack/stroke or new ischemic lesions on cerebral diffusion-weighted magnetic resonance imaging performed at 24 to 48 h.

RESULTS

Occurrence of the primary outcome measure was significantly lower in the 600-mg clopidogrel arm (18% vs. 35.9% in the 300-mg group; p = 0.019) and in the atorvastatin reload arm (18.4% vs. 35.0% in the no statin reload group; p = 0.031). High-dose clopidogrel also significantly reduced the transient ischemic attack/stroke rate at 30 days (0% vs. 9%, p = 0.02, secondary endpoint), without an increase in bleeding risk.

CONCLUSIONS

In patients undergoing carotid stenting, a strategy using both a 600-mg clopidogrel load and a short-term reload with high-dose atorvastatin protects against early ischemic cerebral events. These results, obtained along with routine mechanical neuroprotection, provide new evidence of the optimization of drug therapy before percutaneous carotid intervention. (Clopidogrel and Atorvastatin Treatment During Carotid Artery Stenting [ARMYDA-9 CAROTID]; NCT01572623).