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Cheng CC, Lin CS, Yin WH, Lin C, Liu IF, Lee YF, Liu WT, Fu HN, Huang CL, Tsao TP. The safety and efficacy of the Mo.Ma system device for carotid artery stenting: A single-center experience from Taiwan. Front Cardiovasc Med 2022; 9:926513. [PMID: 36186979 PMCID: PMC9522320 DOI: 10.3389/fcvm.2022.926513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background Proximal protection devices, such as the Mo.Ma system provides better neurological outcomes than the distal filter system in the carotid artery stenting (CAS) procedure. This study first evaluated the safety and efficacy of the Mo.Ma system during CAS in a single tertiary referral hospital from Taiwan. The outcomes of distal vs. proximal embolic protection devices were also studied. Methods A total of 294 patients with carotid artery stenosis who underwent the CAS procedure were retrospectively included and divided into two groups: 152 patients in the distal filter system group and 142 patients in the Mo.Ma system. The outcomes of interest were compared between the two groups. The factors contributing to occlusion intolerance (OI) in the Mo.Ma system were evaluated. Results The procedure success rates were more than 98% in both groups. No major stroke occurred in this study. The minor stroke rates were 2.8% (4/142) and 4.6% (7/152) in the Mo.Ma system and filter system, respectively (p = 0.419). Patients with hypoalbuminemia significantly predicted the risk of stroke with an odds ratio of 0.08 [95% confidence interval (CI), 0.01–0.68, p = 0.020] per 1 g/day of serum albumin in the filter group. A total of 12 patients developed OI in the Mo.Ma system (12/142, 8%). Low occlusion pressure predicted the occurrence of OI in the Mo.Ma group with the hazard ratios of 0.88 (95% CI: 0.82–0.96) and 0.90 (95% CI: 0.84–0.98) per 1 mmHg of occlusion systolic pressure (OSP) and diastolic pressure (ODP), respectively. We further indicated that patients with an OSP of ≥60 mmHg or an ODP of ≥44 mmHg could tolerate the procedure of occlusion time up to 400 s, while patients with an OSP of <49 mmHg or an ODP of <34 mmHg should undergo the procedure of occlusion time less than 300 s to prevent the occurrence of OI. Conclusion We have demonstrated the safety and effectiveness of the Mo.Ma system during CAS in an Asia population. By reducing the occlusion time, our study indicated a lower risk of OI in the Mo.Ma system and proposed the optimal occlusion time according to occlusion pressure to prevent OI during the CAS procedure. Further large-scale and prospective studies are needed to verify our results.
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Affiliation(s)
- Cheng-Chung Cheng
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Hsian Yin
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - I-Fan Liu
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Feng Lee
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Ting Liu
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hao-Neng Fu
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Chien-Lung Huang
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tien-Ping Tsao
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- *Correspondence: Tien-Ping Tsao,
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Kim MS, Rho MH, Hong HP, Park HJ, Chung PW, Won YS. Comparison of Embolic Protection with Proximal and Distal Protection Devices: Periprocedural Complications, Clinical Outcomes, and Cerebral Embolic Lesions on Diffusion-Weighted Magnetic Resonance Imaging. World Neurosurg 2019; 135:e731-e737. [PMID: 31899400 DOI: 10.1016/j.wneu.2019.12.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Two main types of embolic protection devices have been used during carotid artery stenting (CAS): distal protection devices (DPDs) and proximal protection devices (PPDs). We compared the complications, clinical outcomes, and new ischemic lesions on diffusion-weighted magnetic resonance imaging (DWI) studies between patients who had undergone CAS using a DPD or PPD. METHODS We performed a retrospective review of the data from patients who had undergone CAS from March 2010 to January 2016. The periprocedural and 30-day adverse events and new ischemic lesions on DWI studies after CAS were evaluated. RESULTS CAS was performed in 103 patients (DPD, n = 60; PPD, n = 43). The number of patients with new ischemic lesions was greater in the DPD than in the PPD group (78% vs. 56%; P = 0.014). Most lesions (>90%) were tiny (≤3 mm), and the average number of new tiny lesions per patient was significantly greater in the DPD than in the PPD group (mean, 9.6 vs. 4.0; P = 0.008). No significant differences in the periprocedural or 30-day adverse rates were noted between the 2 groups. Intolerance during the procedure occurred in 5 patients (12%) in the PPD group, 4 of whom had poor collateral circulation. CONCLUSIONS The number of new ischemic lesions per patient and the incidence of ischemic lesions found on DWI were significantly greater in the DPD than in the PPD group. The lack of differences in the periprocedural and 30-day adverse rates between the 2 groups suggests that cerebral microemboli might not be associated with the clinical outcomes. For patients with poor collateral status, DPDs should be used preferentially to avoid the neurologic compromise associated with PPDs.
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Affiliation(s)
- Myung Sub Kim
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myung Ho Rho
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Hyun Pyo Hong
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hee Jin Park
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Pil Wook Chung
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yu Sam Won
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Lamanna A, Maingard J, Barras CD, Kok HK, Handelman G, Chandra RV, Thijs V, Brooks DM, Asadi H. Carotid artery stenting: Current state of evidence and future directions. Acta Neurol Scand 2019; 139:318-333. [PMID: 30613950 DOI: 10.1111/ane.13062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 11/29/2022]
Abstract
Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.
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Affiliation(s)
- Anthony Lamanna
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Julian Maingard
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Christen D. Barras
- South Australian Health and Medical Research Institute Adelaide South Australia Australia
- The University of Adelaide Adelaide South Australia Australia
| | - Hong Kuan Kok
- Interventional Radiology ServiceNorthern Hospital Radiology Melbourne, Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
| | - Guy Handelman
- Education and Research CentreBeaumont Hospital Dublin Ireland
- Department of RadiologyRoyal Victoria Hospital Belfast UK
| | - Ronil V. Chandra
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
| | - Vincent Thijs
- Stroke Division, The Florey Institute of Neuroscience & Mental HealthUniversity of Melbourne Melbourne Victoria Australia
- The University of Melbourne Melbourne Victoria Australia
- Department of NeurologyAustin Health Melbourne Victoria Australia
| | - Duncan Mark Brooks
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
| | - Hamed Asadi
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
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Dhillon AS, Li S, Lewinger JP, Shavelle DM, Matthews RV, Clavijo LC, Weaver FA, Garg P. Comparison of devices used in carotid artery stenting: A vascular quality initiative analysis of commonly used carotid stents and embolic protection devices. Catheter Cardiovasc Interv 2018; 92:743-749. [DOI: 10.1002/ccd.27646] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 03/10/2018] [Accepted: 04/02/2018] [Indexed: 11/12/2022]
Affiliation(s)
- Ashwat S. Dhillon
- Division of Cardiovascular Medicine; University of Southern California Keck School of Medicine; Los Angeles California
| | - Sisi Li
- Department of Biostatistics; University of Southern California; Los Angeles California
| | - Juan Pablo Lewinger
- Department of Biostatistics; University of Southern California; Los Angeles California
| | - David M. Shavelle
- Division of Cardiovascular Medicine; University of Southern California Keck School of Medicine; Los Angeles California
| | - Ray V. Matthews
- Division of Cardiovascular Medicine; University of Southern California Keck School of Medicine; Los Angeles California
| | - Leonardo C. Clavijo
- Division of Cardiovascular Medicine; University of Southern California Keck School of Medicine; Los Angeles California
| | - Fred A. Weaver
- Division of Vascular Surgery; University of Southern California Keck School of Medicine; Los Angeles California
| | - Parveen Garg
- Division of Cardiovascular Medicine; University of Southern California Keck School of Medicine; Los Angeles California
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5
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Texakalidis P, Letsos A, Kokkinidis DG, Schizas D, Karaolanis G, Giannopoulos S, Giannopoulos S, Economopoulos KP, Bakoyannis C. Proximal embolic protection versus distal filter protection versus combined protection in carotid artery stenting: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:545-552. [PMID: 29502959 DOI: 10.1016/j.carrev.2017.12.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/22/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Proximal embolic protection devices (P-EPD) and distal filters (DF) are used to prevent distal cerebral embolizations during carotid artery stenting (CAS). We compared their comparative effectiveness in regards to prevention of intraprocedural and periprocedural adverse events, including ischemic lesions (ipsilateral and contralateral), stroke, transient ischemic attacks (TIA) and death. We also compared the combination of the two neuroprotection strategies vs. a single strategy in regards to ischemic lesions and stroke. MATERIALS & METHODS This study was performed according to the PRISMA and MOOSE guidelines and eligible studies were identified through search of PubMed, Scopus and Cochrane Central. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess for heterogeneity. RESULTS Twenty-nine studies involving 16,307 patients were included. There was a significant reduction in ischemic lesions with the use of P-EPD among observational studies (RR: 0.66 [0.45-0.97]). There were no statistically significant differences for the other outcomes between the two treatment groups. CONCLUSIONS There is a number of studies reporting outcomes on the comparison between P-EPD and DF for CAS. P-EDP can reduce distal embolization phenomena resulting into ischemic lesions when compared to DF based on the results from real-world studies. P-EPD was not superior however, in regards to periprocedural stroke, TIA and death. Further studies are anticipated to provide a clear answer to this debate.
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Affiliation(s)
- Pavlos Texakalidis
- Aristotle University of Thessaloniki, Thessaloniki, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece.
| | - Alexandros Letsos
- University of Crete, Heraklion, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Georgios Karaolanis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Stefanos Giannopoulos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Spyridon Giannopoulos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Konstantinos P Economopoulos
- Division of Surgery, Duke University School of Medicine; Society of Junior Doctors, Menalou 5 Street, 15123 Athens, Greece
| | - Christos Bakoyannis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, 11527 Athens, Greece
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Ghanem F, Vodnala D, K Kalavakunta J, Durga S, Thormeier N, Subramaniyam P, Abela S, S Abela G. Cholesterol crystal embolization following plaque rupture: a systemic disease with unusual features. J Biomed Res 2017; 31:82-94. [PMID: 28808190 PMCID: PMC5445211 DOI: 10.7555/jbr.31.20160100] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Cholesterol crystal embolic (CCE) syndrome is often a clinically challenging condition that has a poor prognostic implication. It is a result of plaque rupture with release of cholesterol crystals into the circulation that embolize into various tissue organs. Plaque rupture seems to be triggered by an expanding necrotic core during cholesterol crystallization forming sharp tipped crystals that perforate and tear the fibrous cap. Embolizing cholesterol crystals then initiate both local and systemic inflammation that eventually lead to vascular fibrosis and obstruction causing symptoms that can mimic other vasculitic conditions. In fact, animal studies have demonstrated that cholesterol crystals can trigger an inflammatory response via NLRP3 inflammasome similar to that seen with gout. The diagnosis of CCE syndrome often requires a high suspicion of the condition. Serum inflammation biomarkers including elevated sedimentation rate, abnormal renal function tests and eosinophilia are useful but non-specific. Common target organ involvement includes the skin, kidney, and brain. Various testing including fundoscopic eye examination and other non-invasive procedures such as trans-esophageal echocardiography and magnetic resonance imaging may be helpful in identifying the embolic source. Treatment includes aspirin and clopidogrel, high dose statin and possibly steroids. In rare cases, mechanical intervention using covered stents may help isolate the ruptured plaque. Anticoagulation with warfarin is not recommended and might even be harmful. Overall, CCE syndrome is usually a harbinger of extensive and unstable atherosclerotic disease that is often associated with acute cardiovascular events.
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Affiliation(s)
- Firas Ghanem
- Department of Medicine, Division of Cardiology, College of Human Medicine, Michigan State University, East Lansing, MI, USA; Wheaton Franciscan Health, Brookfield, WI, USA
| | - Deepthi Vodnala
- University of Missouri, St. Luke's Health System, Kansas City, MO 48824, USA
| | - Jagadeesh K Kalavakunta
- Department of Medicine, Division of Cardiology, College of Human Medicine, Michigan State University, East Lansing, MI, USA.,Borgess Hospital, Kalamazoo, MI, USA
| | - Sridevi Durga
- Department of Medicine, Division of Cardiology, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Noah Thormeier
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Prem Subramaniyam
- Department of Medicine, Division of Cardiology, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Scott Abela
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - George S Abela
- Department of Medicine, Division of Cardiology, College of Human Medicine, Michigan State University, East Lansing, MI, USA.,Department of Physiology, Division of Pathology, College of Human Medicine, Michigan State University, East Lansing, MI, USA
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7
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Kambayashi Y, Yuki I, Ishibashi T, Ikemura A, Umezawa T, Suzuki M, Kan I, Takao H, Murayama Y. Immunohistochemical Analysis of Debris Captured by Filter-Type Distal Embolic Protection Devices for Carotid Artery Stenting. J Stroke Cerebrovasc Dis 2016; 26:816-822. [PMID: 27865698 DOI: 10.1016/j.jstrokecerebrovasdis.2016.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 10/02/2016] [Accepted: 10/23/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Little is known about the micro-debris captured in filter-type distal embolic protection devices (EPD) used for carotid stenting (CAS). This study aimed to determine the histological and immunohistochemical characteristics of such debris by using a new liquid-based cytology (LBC) technique. METHODS Fifteen patients who underwent CAS using a filter-type distal EPD (FilterWire EZ; Boston Scientific, Marlborough, MA, USA) were included in the study. After gross inspection of each recovered filter device, micro-debris were collected using a new LBC technique (SurePath; TriPath Imaging, Inc., Burlington, NC). Histological and immunohistochemical analysis of the recovered debris was performed. The pre- and postoperative brain magnetic resonance imaging and neurological status of each patient were also reviewed. RESULTS No patient developed ipsilateral symptomatic stroke due to a thromboembolic event. All 15 patients (100%) had microscopically identifiable debris in the filters, whereas gross inspection detected visible debris only in 5 patients (33.3%). Histological analysis revealed various types of structural components in an advanced atheromatous plaque, including fragments of fibrous cap, calcified plaque, smooth muscle cells, and necrotic tissue fragment infiltrated with monocytes and macrophages. CONCLUSIONS Filter-type EPDs may contribute to reducing the risk of CAS-related embolic events by capturing micro-debris even when gross inspection of the recovered filter shows no visible debris in the device.
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Affiliation(s)
| | - Ichiro Yuki
- Department of Neurosurgery, Jikei University School of Medicine, Japan.
| | | | - Ayako Ikemura
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Takashi Umezawa
- Department of Pathology, Jikei University School of Medicine, Japan
| | - Masafumi Suzuki
- Department of Pathology, Jikei University School of Medicine, Japan
| | - Issei Kan
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Hiroyuki Takao
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, Jikei University School of Medicine, Japan
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Morr S, Lin N, Siddiqui AH. Carotid artery stenting: current and emerging options. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 7:343-55. [PMID: 25349483 PMCID: PMC4208632 DOI: 10.2147/mder.s46044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Simon Morr
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Ning Lin
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Department of Radiology, School of Medicine and Biomedical Sciences, Buffalo, NY, USA ; Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, NY, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA ; Jacobs Institute, Buffalo, NY, USA
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Badheka AO, Chothani A, Panaich SS, Mehta K, Patel NJ, Deshmukh A, Singh V, Arora S, Patel N, Grover P, Shah N, Savani CN, Patel A, Panchal V, Brown M, Kaki A, Kondur A, Mohamad T, Elder M, Grines C, Schreiber T. Impact of symptoms, gender, co-morbidities, and operator volume on outcome of carotid artery stenting (from the Nationwide Inpatient Sample [2006 to 2010]). Am J Cardiol 2014; 114:933-41. [PMID: 25208563 DOI: 10.1016/j.amjcard.2014.06.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 06/10/2014] [Accepted: 06/10/2014] [Indexed: 10/25/2022]
Abstract
The increase in the number of carotid artery stenting (CAS) procedures over the last decade has necessitated critical appraisal of procedural outcomes and patterns of utilization including cost analysis. The main objectives of our study were to evaluate the postprocedural mortality and complications after CAS and the patterns of resource utilization in terms of length of stay (LOS) and cost of hospitalization. We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2006 to 2010 using the International Classification of Diseases, Ninth Revision, procedure code of 00.63 for CAS. Hierarchical mixed-effects models were generated to identify the independent multivariate predictors of in-hospital mortality, procedural complications, LOS, and cost of hospitalization. A total of 13,564 CAS procedures (weighted n = 67,344) were analyzed. The overall postprocedural mortality was low at 0.5%, whereas the complication rate was 8%, both of which remained relatively steady over the time frame of the study. Greater postoperative mortality and complications were noted in symptomatic patients, women, and those with greater burden of baseline co-morbidities. A greater operator volume was associated with a lower rate of postoperative mortality and complications, as well as shorter LOS and lesser hospitalization costs. In conclusion, the postprocedural mortality after CAS has remained low over the recent years. Operator volume is an important predictor of postprocedural outcomes and resource utilization.
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10
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Hayashi K, Horie N, Morikawa M, Yamaguchi S, Fukuda S, Morofuji Y, Izumo T, Nagata I. Pathophysiology of flow impairment during carotid artery stenting with an embolus protection filter. Acta Neurochir (Wien) 2014; 156:1721-8. [PMID: 25037465 DOI: 10.1007/s00701-014-2180-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 07/09/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Carotid artery stenting (CAS) is a well-accepted treatment for atherosclerotic stenosis of carotid arteries. Since the occurrence of distal embolization with CAS is still a major concern embolus protection devices (EPD) are usually employed during the procedure. We examined two types of embolus protection filters (Angioguard XP (AG); Filterwire EZ (FW)) and evaluated the function. Thus, the filter was examined postoperatively and the cause of intraoperative flow impairment was evaluated. MATERIALS AND METHODS CAS was performed for 54 patients with carotid artery stenosis (55 lesions: 25 AG; 27 FW; 3 others). After completing CAS the filter membrane was stained with hematoxylin-eosin (HE) solution and removed from the filter strut. Once mounted on a glass slide the filter was evaluated under a microscope. The area occupied with debris was measured and the relationship to intraoperative flow impairment was evaluated. Furthermore, the relationship between perioperative ischemic complications and intraoperative flow impairment was statistically analyzed. RESULTS Microscopic observation of the slide revealed the pore density of the FW was 1.5 times higher than that of the AG and the filter area of the FW was 2.5 times wider than than the AG. HE staining facilitated characterization of the debris composition. The area occupied with debris was significantly more in the AG (0.241 ± 0.13 cm(2)) than in the FW (0.129 ± 0.093 cm(2)). Thus, fibrin was significantly more precipitated in the AG. Flow impairment occurred in 6 AG cases (24.0 %) and 4 FW cases (14.8 %). It was induced by filter obstruction in the AG and by vasospasms in the FW. Three cases treated with AG (12.0 %) were complicated with cerebral infarction and all of them were related to flow impairment. One FW case (3.7 %) was complicated with cerebral infarction in presence of preserved flow throughout the intervention. CONCLUSION Filter function is different according to each design. The cause of flow impairment was attributable to filter obstruction in the AG group and to vasospasms in the FW group. Filter obstruction tends to result in cerebral infarction.
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Affiliation(s)
- Kentaro Hayashi
- Department of Neurosurgery, Nagasaki University School of Medicine, Sakamoto 1-7-1, Nagasaki City, Nagasaki, 852-8501, Japan,
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11
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Iko M, Aikawa H, Go Y, Nakai K, Tsutsumi M, Yu I, Mizokami T, Sakamoto K, Inoue R, Mitsutake T, Eto A, Hanada H, Kazekawa K. Treatment outcomes of carotid artery stenting with two types of distal protection filter device. SPRINGERPLUS 2014; 3:132. [PMID: 25674435 PMCID: PMC4320198 DOI: 10.1186/2193-1801-3-132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 02/21/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE Preventing cerebral embolism from debris produced during carotid artery stenting (CAS) is important. This study compared the treatment outcomes of CAS using two types of filter-based embolic protection devices currently in use in Japan. MATERIALS AND METHODS We assessed 121 consecutive cases of CAS performed with FilterWire EZ™ between July 2010 and November 2012 and 37 consecutive cases of CAS performed with the Spider FX™ between November 2012 and June 2013. A Carotid Wallstent™ was used in all cases. The incidence of positive lesions on diffusion-weighted magnetic resonance imaging (DWI) and stroke were compared between the groups. RESULTS Postoperative DWI-positive lesions were observed in 38 (31.4%) and 14 (37.8%) patients in the FilterWire and Spider groups, respectively. In the FilterWire group, complications were transient ischemic attacks in 3 (2.5%) patients, cerebral infarction in 2 (1.7%) patients (1 patient each with minor and major stroke), and cerebral hemorrhage due to hyperperfusion syndrome in 1 (0.8%) patient. In the Spider group, except for cerebral infarction (minor stroke) in 1 (2.7%) patient, no complications were observed. No significant differences were observed in the incidence of complications between the groups. CONCLUSION FilterWire EZ and Spider FX are comparable in terms of treatment outcome.
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Affiliation(s)
- Minoru Iko
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Hiroshi Aikawa
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Yoshinori Go
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Kanji Nakai
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Masanori Tsutsumi
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Iwae Yu
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Taichiro Mizokami
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Kimiya Sakamoto
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Ritsuro Inoue
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Takafumi Mitsutake
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Ayumu Eto
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Hayatsura Hanada
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
| | - Kiyoshi Kazekawa
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, Fukuoka, 818-8502 Japan
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Nakagawa I, Wada T, Park HS, Nishimura F, Yamada S, Nakagawa H, Kichikawa K, Nakase H. Platelet inhibition by adjunctive cilostazol suppresses the frequency of cerebral ischemic lesions after carotid artery stenting in patients with carotid artery stenosis. J Vasc Surg 2014; 59:761-7. [DOI: 10.1016/j.jvs.2013.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 09/05/2013] [Accepted: 09/06/2013] [Indexed: 11/25/2022]
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Langhoff R, Mudra H, Waliszewski M, Reimers B, Berge J, Setacci C, Beyssen B. Outcome of carotid angioplasty with a novel open-cell carotid stent system. Vasc Endovascular Surg 2014; 48:317-24. [PMID: 24488211 DOI: 10.1177/1538574413520517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The choice of carotid stent systems depends primarily on the anatomy of the carotid artery, the lesion morphology, and the patient's risk factors. Design improvements in devices, in terms of crossing profile and the ability to precisely position the stent, may greatly contribute to the procedural success without compromising acute clinical outcomes. METHODS AND RESULTS The primary objective of this clinical registry was to evaluate the early safety and efficacy of a novel open-cell carotid stent system in an "all comer" population suitable for carotid artery stenting. The primary end point was the composite of ipsilateral stroke and "all-cause mortality" within 30 days after the procedure. Secondary end points entailed the rates of myocardial infarction and other clinical complications within the first 30 days following the procedure and up to the 6-month follow-up. Unsuccessful placement and/or withdrawal of the delivery system, as well as device-related complications involving the carotid artery and the rate of nonlesion-related embolisms, were evaluated relative to other currently available carotid stents. The 30-day composite death/stroke rate was 2.8% (3 of 106) while the overall stent system performance was similar to commonly used carotid stent systems. CONCLUSIONS The utilized open-cell carotid stent system had favorable lesion crossing and positioning characteristics without compromising the 30-day composite death/stroke rate.
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Affiliation(s)
- Ralf Langhoff
- Innere Medizin, Kardiologie, Angiologie und Diabetologie, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany
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14
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Giri J, Kennedy KF, Weinberg I, Hawkins BM, Press MC, Drachman D, McCormick DJ, Aronow HD, White CJ, Rosenfield K, Yeh RW. Comparative Effectiveness of Commonly Used Devices for Carotid Artery Stenting. JACC Cardiovasc Interv 2014; 7:171-177. [DOI: 10.1016/j.jcin.2013.10.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 09/25/2013] [Accepted: 10/04/2013] [Indexed: 11/26/2022]
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Henry M, Polydorou A, Henry I, Polydorou AD, Hugel M. Carotid angioplasty and stenting under protection: advantages and drawbacks. Expert Rev Med Devices 2014; 5:591-603. [DOI: 10.1586/17434440.5.5.591] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tatli E, Buturak A, Grunduz Y, Dogan E, Alkan M, Sayin M, Yilmaztepe M, Atakay S. Comparison of anti-embolic protection with proximal balloon occlusion and filter devices during carotid artery stenting: clinical and procedural outcomes. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2013; 9:221-7. [PMID: 24570722 PMCID: PMC3915994 DOI: 10.5114/pwki.2013.37499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 04/18/2013] [Accepted: 05/16/2013] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Ersan Tatli
- Department of Cardiology, Ada TIp Hospital, Sakarya, Turkey
| | - Ali Buturak
- Department of Cardiology, Acibadem University Hospital, Istanbul, Turkey
| | - Yasemin Grunduz
- Department of Radiology, Sakarya University, School of Medicine, Sakarya, Turkey
| | - Emir Dogan
- Department of Cardiology, Ada TIp Hospital, Sakarya, Turkey
| | - Mustafa Alkan
- Department of Cardiology, Ada TIp Hospital, Sakarya, Turkey
| | - Murat Sayin
- Department of Neurosurgery, Ada TIp Hospital, Sakarya, Turkey
| | | | - Selcuk Atakay
- Department of Neurosurgery, Ada TIp Hospital, Sakarya, Turkey
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A new method for protection from shower embolism during TEVAR on a shaggy aorta. Gen Thorac Cardiovasc Surg 2013; 63:105-8. [DOI: 10.1007/s11748-013-0278-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 06/12/2013] [Indexed: 10/26/2022]
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Velasco A, Mosimann PJ. Distal cerebral protection device filled with calcified plaque debris after carotid stenting. JACC Cardiovasc Interv 2013; 6:e22-3. [PMID: 23597618 DOI: 10.1016/j.jcin.2012.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 10/26/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Aglaé Velasco
- Hospital Universitario Virgen del Rocio, Unidad de Neurorradiología Intervencionista, Sevilla, Spain
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Loghmanpour NA, Siewiorek GM, Wanamaker KM, Muluk SC, Chaer R, Wholey MH, Finol EA. Assessing the impact of distal protection filter design characteristics on 30-day outcomes of carotid artery stenting procedures. J Vasc Surg 2012; 57:309-317.e2. [PMID: 23265587 DOI: 10.1016/j.jvs.2012.08.113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Revised: 08/20/2012] [Accepted: 08/22/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study aims to review retrospectively the records of patients treated with carotid artery stenting (CAS) to investigate the potential correlations between clinical variables, distal protection filter (DPF) type and characteristics, and 30-day peri-/postprocedural outcomes. METHODS This is a multicenter, single-arm, nonrandomized retrospective study of patients who underwent filter-protected CAS in the Pittsburgh, Pennsylvania, region between July 2000 and May 2011. Analysis of peri-/postprocedural complications included myocardial infarction, transient ischemic attacks (TIA), stroke, death, and a composition of all adverse events (AEs). Filter characteristics for Accunet (Abbott Vascular, Santa Clara, Calif; n = 429 [58.8%]), Angioguard (Cordis Endovascular, Miami Lakes, Fla; n = 114 [15.6%]), FilterWire (Boston Scientific, Natick, Mass; n = 113 [15.5%]), Spider (ev3 Endovascular, Plymouth, Minn; n = 45 [6.2%]), and Emboshield (Abbott Vascular; n = 24 [3.3%]) were previously determined in vitro and were used to find correlations with CAS procedural outcomes. Both univariate and multivariate analyses were performed, as well as goodness-of-fit tests to find multivariate correlations with procedural outcomes. RESULTS In total, 731 CAS procedures using six different DPFs were analyzed. Peri-/postprocedural AEs included 19 TIAs (2.6%), 38 strokes (5.2%), one myocardial infarction (0.1%), 19 deaths (3.6%), and a total of 61 patients with complications (8.3%). Univariate analysis for filter design characteristics showed that the composite of AE was negatively associated with both vascular resistance (P = .01) and eccentricity (P = .02) and was positively associated with porosity (P = .0007), number of pores (P = .005), and pore density (P = .001). Multivariate analysis and the goodness-of-fit test revealed that patients with a history of congestive heart failure, stroke, and TIA (each with odds ratio >1) led to a good-fit model P value of .72 for peri-/postprocedural AEs. Multivariate analysis was inconclusive for all filter design characteristics. CONCLUSIONS The following filter design characteristics are independently significant for minimizing peri-/postprocedural AEs: higher vascular resistance, concentric in shape, greater capture efficiency, lower porosity, lower number of pores, and lower pore density. Lower porosity and smaller wall apposition were also found to be independently significant for minimization of peri-/postprocedural TIAs. This information can be used when considering the desirable design characteristics of future DPFs.).
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20
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Mousa AY, Campbell JE, AbuRahma AF, Bates MC. Current update of cerebral embolic protection devices. J Vasc Surg 2012; 56:1429-37. [DOI: 10.1016/j.jvs.2012.05.077] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 03/19/2012] [Accepted: 05/16/2012] [Indexed: 11/30/2022]
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Setacci C, Sirignano P, Galzerano G, Setacci F. Urgent CAS: a revolution in the treatment of symptomatic patients in the hyperacute phase. J Endovasc Ther 2012; 19:636-7. [PMID: 23046329 DOI: 10.1583/jevt-12-3852c.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Carlo Setacci
- Vascular and Endovascular Surgery Unit, Department of Surgery, University of Siena, Italy.
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Van der Heyden J, Wolters FJ, Garin N, Blant SA, Inglin M, Bal ET, Suttorp JM. The role of embolic protection devices during carotid stenting prior to cardiac surgery in asymptomatic patients: empty filters? Catheter Cardiovasc Interv 2012; 80:112-9. [PMID: 21953787 DOI: 10.1002/ccd.23383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 08/03/2011] [Accepted: 09/09/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The purpose of this study was to analyze the debris captured in the distal protection filters used during carotid artery stenting (CAS). BACKGROUND CAS is an option available to high-risk patients requiring revascularization. Filters are suggested for optimal stroke prevention during CAS. METHODS From May 2005 to June 2007, filters from 59 asymptomatic patients who underwent CAS were collected and sent to a specialized laboratory for light-microscope and histological analysis. Peri- and postprocedural outcomes were assessed during 1-year follow-up. RESULTS On the basis of biomedical imaging of the filter debris, the captured material could not be identified as embolized particles from the carotid plaque. On histological analysis the debris consisted mainly of red blood cell aggregates and/ or platelets, occasionally accompanied by granulocytes. We found no consistent histological evidence of embolized particles originating from atherosclerotic plaques. Post-procedure, three neurological events were reported: two (3.4%) transient ischemic attacks (TIA) and one (1.7%) ipsilateral minor stroke. CONCLUSION The filters used during CAS in asymptomatic patients planned for cardiac surgery often remained empty. These findings may be explained by assuming that asymptomatic patients feature a different atherosclerotic plaque composition or stabilization through antiplatelet medication. Larger, randomized trials are clearly warranted, especially in the asymptomatic population.
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Affiliation(s)
- Jan Van der Heyden
- Department of Interventional Cardiology, St-Antonius Hospital, Nieuwegein, The Netherlands.
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Stojanov D, Ilic M, Bosnjakovic P, Zivkovic M, Jolic S, Vukasinovic N, Ignjatovic A, Ilic B, Benedeto-Stojanov D. New ischemic brain lesions on diffusion-weighted MRI after carotid artery stenting with filter protection: frequency and relationship with plaque morphology. AJNR Am J Neuroradiol 2011; 33:708-14. [PMID: 22194373 DOI: 10.3174/ajnr.a2840] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CAS carries an inherent risk of distal cerebral embolization, precipitating new brain ischemic lesions and neurologic symptoms. Our purpose was to evaluate the frequency of new ischemic lesions found on DWI after protected CAS placement and to determine its association with plaque morphology. MATERIALS AND METHODS Fifty patients (mean age 65.13 ± 7.08 years) with moderate and severe internal carotid artery stenosis underwent CAS with distal filter protection. Fibrolipid and fibrocalcified plaque morphology was determined by sonography according to the relative contribution of echogenic and echolucent material, and by multisection CT using plaque attenuation. There were 46.81% of patients with fibrolipid and 53.19% with fibrocalcified plaques. DWI was performed before and 24 hours after CAS. RESULTS Seven (14.89%) patients showed new lesions. Four (8.51%) had 6 new lesions inside the treated vascular territory. Three had a single lesion and 1 patient had 3 lesions (mean: 1.5 ± 1). Most lesions (66.66%) were subcortical, with a mean diameter of 9 mm (range 5-15 mm). All lesions occurred in the area supplied by the middle cerebral artery and were clinically silent. A significant relationship was found between plaque morphology and the appearance of new lesions. Patients with fibrolipid plaques had a significantly higher number of new lesions compared with patients with fibrocalcified plaques (P = .041). The absolute risk of new lesions in the fibrolipid group was 18.18%. CONCLUSIONS New ischemic lesions were observed in the treated vascular territory in 8.51% of patients. The appearance of new ischemic lesions was significantly related to the plaque morphology. Fibrolipid plaques were associated with higher numbers of new lesions.
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Affiliation(s)
- D Stojanov
- Institute of Radiology, Clinical Center Nis, Nis, Serbia
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Siewiorek GM, Krafty RT, Wholey MH, Finol EA. The association of clinical variables and filter design with carotid artery stenting thirty-day outcome. Eur J Vasc Endovasc Surg 2011; 42:282-91. [PMID: 21530332 PMCID: PMC3157584 DOI: 10.1016/j.ejvs.2011.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Accepted: 04/02/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Patient and device selection are important for the success of carotid artery stenting (CAS). We hypothesize that distal protection filter (DPF) design characteristics that minimize blood flow resistance and maximize capture efficiency are associated with the absence of transient ischemic attack (TIA), stroke and neurologic-related death after 30 days. METHODS Records from 208 patients were reviewed retrospectively. Filter design characteristics were quantified previously in our laboratory. The association between risk factors and design characteristics with 30-day outcome was quantified using univariate analysis. RESULTS The 30-day all-cause stroke and death rate was 8.7% (asymptomatic: 7.7%, symptomatic: 10.6%). Five DPFs were used in the study: Accunet (41.3%), Angioguard (33.2%), FilterWire (24%), Emboshield (1%), and Spider (.5%). Diabetes (P = .04) and prior carotid endarterectomy (CEA, P = .03) were associated with adverse outcome. Prior stroke (P = .01) and prior CEA (P = .04) were significant for peri-procedural stroke. Design characteristics such as capture efficiency were associated with favorable outcomes. CONCLUSIONS Patients with prior CEA or stroke are more likely to have unfavorable CAS outcomes after 30 days. Filters with high capture efficiency may yield the best clinical results. Analysis of the effect of design characteristics on CAS outcome should aid the design of future devices.
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Affiliation(s)
- Gail M. Siewiorek
- Biomedical Engineering Department Carnegie Mellon University 1210 Hamburg Hall 5000 Forbes Avenue Pittsburgh, PA 15213 USA
| | - Robert T. Krafty
- Department of Statistics University of Pittsburgh 2702 Cathedral of Learning Pittsburgh, PA 15260 USA
| | - Mark H. Wholey
- University of Pittsburgh Medical Center – Shadyside 5230 Centre Avenue, Suite 603 Pittsburgh, PA 15232 USA
| | - Ender A. Finol
- Biomedical Engineering Department Carnegie Mellon University 1210 Hamburg Hall 5000 Forbes Avenue Pittsburgh, PA 15213 USA
- Institute for Complex Engineered Systems and Department of Mechanical Engineering 1205 Hamburg Hall 5000 Forbes Avenue Carnegie Mellon University Pittsburgh, PA 15213 USA
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Naggara O, Touzé E, Beyssen B, Trinquart L, Chatellier G, Meder JF, Mas JL. Anatomical and technical factors associated with stroke or death during carotid angioplasty and stenting: results from the endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial and systematic review. Stroke 2010; 42:380-8. [PMID: 21183750 DOI: 10.1161/strokeaha.110.588772] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purposes of this study were to assess the relationships between anatomic and technical factors and the 30-day risk of stroke or death after carotid angioplasty and stenting in the Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial and to perform a systematic review of the literature. METHODS We included patients from EVA-3S in whom carotid stenting was attempted irrespective of allocated treatment. Two radiologists blinded to clinical data independently assessed the aortic arch and carotid arteries on procedural angiograms. In addition, we performed a systematic review of studies that reported 30-day risk of stroke or death in relation with arterial anatomy and technique. Outcomes were stroke or death and stroke occurring within 30 days of the carotid angioplasty and stenting procedure. RESULTS Two hundred sixty-two patients from EVA-3S fulfilled the inclusion criteria (including 1 initially allocated to surgery and 13 in whom stent insertion failed).Within 30 days after the procedure, 25 (9.5%) patients had a stroke or had died. The risk of stroke or death was higher in patients with internal carotid artery-common carotid artery angulation ≥60° (relative risk, 4.96; 2.29 to 10.74) and lower in those treated with cerebral protection devices (relative risk [RR], 0.38; 0.17 to 0.85). In the systematic review (56 studies; 34 398 patients), the risk of stroke or death was higher in patients with left-sided carotid angioplasty and stenting (RR, 1.29; 1.05 to 1.58), increased internal carotid artery-common carotid artery angulation (RR, 3.41; 1.52 to 7.63), and when the target internal carotid artery stenosis was >10 mm (RR, 2.36; 1.28 to 3.38). There was no significant increase in risk of stroke or death in patients with Type III aortic arch, aortic arch calcification, or with ostial involvement, calcification, ulceration or degree of stenosis of the target internal carotid artery stenosis. The use of a cerebral protection device was associated with a lower risk of stroke or death (RR, 0.55; 0.41 to 0.73). Risk was not related with stent or cerebral protection device type. CONCLUSIONS Our results strongly suggest that some technical and anatomic factors, especially extreme angulation of the carotid artery, have an impact on the risks of carotid angioplasty and stenting.
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Affiliation(s)
- Olivier Naggara
- Université Paris Descartes, INSERM UMR 894, Department of Neurology, Hôpital Sainte-Anne, 75014 Paris, France
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Macdonald S. Role of filter design in embolic protection during carotid artery stenting. Interv Cardiol 2009. [DOI: 10.2217/ica.09.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bedogni F, Laudisa ML, Brambilla N, Pizzocri S, Testa L. Prevention and treatment of complications during carotid artery stenting. Interv Cardiol 2009. [DOI: 10.2217/ica.09.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Karkos CD, Karamanos DG, Papazoglou KO, Demiropoulos FP, Papadimitriou DN, Gerassimidis TS. Thirty-Day Outcome Following Carotid Artery Stenting: A 10-Year Experience from a Single Center. Cardiovasc Intervent Radiol 2009; 33:34-40. [DOI: 10.1007/s00270-009-9746-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Accepted: 10/12/2009] [Indexed: 01/01/2023]
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Henry M, Henry I, Polydorou A, Hugel M. How to avoid complications associated with carotid angioplasty and stenting. Future Cardiol 2009; 4:617-38. [PMID: 19804356 DOI: 10.2217/14796678.4.6.617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Carotid angioplasty and stenting (CAS) has been proposed as an alternative to surgery and is now performed more frequently and is well accepted, at least for high surgical risk patients. However, complications and particularly embolic strokes, even with a meticulous technique, can occur at any step of the procedure. Silent embolism is detected after CAS and may be a problem that needs to be discussed. To avoid and reduce these complications associated with CAS, it is important to have good indications dependent upon on good patient and lesions selection, as well as correct technique. New parameters have been proposed, particularly for asymptomatic lesions. The authors consider that embolic protection devices (EPDs) are mandatory for CAS, and new techniques will be presented. The choice of the EPD depends on the clinical status of the patient, the lesion morphology and characteristics, and the anatomy of the artery. All stents are not equivalent and so a good choice of the stent is necessary to avoid and reduce the complications associated with CAS, and experienced operators are also needed. With all these considerations, CAS can now be performed with acceptable outcomes and in certain population the results are comparable or superior to surgery. The results of ongoing randomized trials are awaited.
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Affiliation(s)
- M Henry
- Cabinet de Cardiologie, 80 Rue Raymond Poincaré, 54000 Nancy, France.
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Distal filtration versus flow reversal: An ex vivo assessment of the choices for carotid embolic protection. J Vasc Surg 2009; 49:1181-8. [DOI: 10.1016/j.jvs.2008.12.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 12/11/2008] [Accepted: 12/12/2008] [Indexed: 11/22/2022]
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Liapis CD, Bell PRF, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes J, Biasi G, Norgren L. ESVS Guidelines. Invasive Treatment for Carotid Stenosis: Indications, Techniques. Eur J Vasc Endovasc Surg 2009; 37:1-19. [PMID: 19286127 DOI: 10.1016/j.ejvs.2008.11.006] [Citation(s) in RCA: 412] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 11/07/2008] [Indexed: 12/18/2022]
Affiliation(s)
- C D Liapis
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
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Perona F, Castellazzi G, Valvassori L, Boccardi E, de Girolamo L, Cornalba GP, Kandarpa K. Safety of Unprotected Carotid Artery Stent Placement in Symptomatic and Asymptomatic Patients: A Retrospective Analysis of 30-day Combined Adverse Outcomes. Radiology 2009; 250:178-83. [DOI: 10.1148/radiol.2493080057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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de Donato G, Setacci C, Deloose K, Peeters P, Cremonesi A, Bosiers M. Long-term results of carotid artery stenting. J Vasc Surg 2008; 48:1431-40; discussion 1440-1. [PMID: 18848755 DOI: 10.1016/j.jvs.2008.07.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Revised: 06/30/2008] [Accepted: 07/03/2008] [Indexed: 11/15/2022]
Affiliation(s)
- Gianmarco de Donato
- Department of Vascular and Endovascular Surgery, University of Siena, Siena, Italy.
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Gortler D, Schlösser FJ, Muhs BE, Nelson MA, Dardik† A. Periprocedural Drug Therapy in Carotid Artery Stenting: The Need for More Evidence. Vascular 2008; 16:303-9. [DOI: 10.2310/6670.2008.00081] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Carotid artery stenting (CAS) is a widely accepted alternative for patients at high risk for carotid endarterectomy (CEA). However, the role, indications, and evidence for many pharmacologic agents that are used adjunctively in the periprocedural setting have not been established. Several drugs are commonly used before, during, and after CAS, but their uses have not been standardized. Large prospective cohort studies with good validity or randomized trials are needed to demonstrate efficacy, predict outcome, and determine the optimal use of these medications in patients undergoing CAS to improve patient care and obtain optimal outcomes. Several conclusions can be made: (1) dual-antiplatelet therapy (aspirin and clopidogrel) is commonly used for CAS; (2) the most commonly used regimen is aspirin 325 mg and clopidogrel 75 mg per day, but the optimal time of therapy is unknown; and (3) the dose and regimen of other agents used for CAS are not established.
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Affiliation(s)
- David Gortler
- Departments of *Pharmacology and †Surgery, Yale University School of Medicine, New Haven, CT; and the **VA Connecticut Healthcare System, West Haven, CT; ***Beth Israel Deaconess Medical Center, Department of Cardiology, Harvard University, Boston, MA
| | - Felix J.V. Schlösser
- Departments of *Pharmacology and †Surgery, Yale University School of Medicine, New Haven, CT; and the **VA Connecticut Healthcare System, West Haven, CT; ***Beth Israel Deaconess Medical Center, Department of Cardiology, Harvard University, Boston, MA
| | - Bart E. Muhs
- Departments of *Pharmacology and †Surgery, Yale University School of Medicine, New Haven, CT; and the **VA Connecticut Healthcare System, West Haven, CT; ***Beth Israel Deaconess Medical Center, Department of Cardiology, Harvard University, Boston, MA
| | - Michael A. Nelson
- Departments of *Pharmacology and †Surgery, Yale University School of Medicine, New Haven, CT; and the **VA Connecticut Healthcare System, West Haven, CT; ***Beth Israel Deaconess Medical Center, Department of Cardiology, Harvard University, Boston, MA
| | - Alan Dardik†
- Departments of *Pharmacology and †Surgery, Yale University School of Medicine, New Haven, CT; and the **VA Connecticut Healthcare System, West Haven, CT; ***Beth Israel Deaconess Medical Center, Department of Cardiology, Harvard University, Boston, MA
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Maldonado TS, Loh S, Fonseco R, Poblete H, Adelman MA, Cayne NS, Mussa F, Rockman CB, Sadik M, Ellozy S, Faries P. Incidence and Outcome of Filter Occlusion during Carotid Artery Stent Procedure. Ann Vasc Surg 2008; 22:756-61. [DOI: 10.1016/j.avsg.2008.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 07/21/2008] [Accepted: 08/05/2008] [Indexed: 11/15/2022]
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Abstract
While popularization of carotid bifurcation intervention occurred only 10 years ago, the rapidity with which technology changed in performing the procedure was astounding. Restrictions upon the performance of the procedure has likely held off continued rapid advancement, nevertheless, there are devices currently in trial and more that have at least been conceived of which will decrease the risks associated with carotid bifurcation intervention. In the following article, device advances that the practicing carotid interventionalist can expect to see within the next few years are reviewed and a look to the future is presented as well.
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Affiliation(s)
- Daniel G Clair
- Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Intraprocedural plaque protrusion resulting in cerebral embolism during carotid angioplasty with stenting. ACTA ACUST UNITED AC 2008; 26:318-23. [PMID: 18661218 DOI: 10.1007/s11604-008-0231-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Accepted: 01/18/2008] [Indexed: 11/27/2022]
Abstract
An 82-year-old man with an asymptomatic left high-grade carotid stenosis was treated with carotid artery stenting (CAS) under distal protection. The procedure consisted with predilation with a 5 x 40 mm percutaneous transluminal angioplasty (PTA) balloon, deployment of a 10 x 20 mm self-expandable stent, post-dilation with a 7 x 20 mm PTA balloon, and aspiration of debris with 60 ml of blood. The cervical carotid angiogram immediately after deflation of the distal blocking balloon demonstrated a small in-stent filling defect of the contrast medium that protruded from the anterior wall of the carotid artery. The following cranial carotid angiogram showed abrupt occlusion of the left middle cerebral artery (MCA). Because the in-stent lesion had vanished in the repeat study after recognition of this embolic event, it was suggested that an embolus had been liberated from the in-stent lesion, reaching the left MCA and obliterating it. In this case, the embolus was speculated to originate in the ruptured plaque, which protruded into the stent through the cells of the device and became liberated into the bloodstream. Attention should be paid so as not to overlook any plaque protrusion, which may be seen subsequently as a cerebral embolism on the angiogram obtained immediately after CAS.
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Bosiers M, Deloose K, Verbist J, Peeters P. What Practical Factors Guide the Choice of Stent and Protection Device during Carotid Angioplasty? Eur J Vasc Endovasc Surg 2008; 35:637-43. [DOI: 10.1016/j.ejvs.2008.02.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Accepted: 02/29/2008] [Indexed: 10/22/2022]
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Kaluski E, Tsai S, Klapholz M. Coronary stenting with MGuard: from conception to human trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2008; 9:88-94. [DOI: 10.1016/j.carrev.2007.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Revised: 12/03/2007] [Accepted: 12/04/2007] [Indexed: 10/22/2022]
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Barbato JE, Dillavou E, Horowitz MB, Jovin TG, Kanal E, David S, Makaroun MS. A randomized trial of carotid artery stenting with and without cerebral protection. J Vasc Surg 2008; 47:760-5. [DOI: 10.1016/j.jvs.2007.11.058] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Revised: 11/14/2007] [Accepted: 11/24/2007] [Indexed: 10/22/2022]
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Kastrup A, Gröschel K, Nägele T, Riecker A, Schmidt F, Schnaudigel S, Ernemann U. Effects of age and symptom status on silent ischemic lesions after carotid stenting with and without the use of distal filter devices. AJNR Am J Neuroradiol 2007; 29:608-12. [PMID: 18065503 DOI: 10.3174/ajnr.a0871] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The routine use of distal filter devices during carotid angioplasty and stent placement (CAS) is controversial. The aim of this study was to analyze their effects on the incidence of new diffusion-weighted imaging (DWI) lesions as surrogate markers for stroke in important subgroups. MATERIALS AND METHODS DWI was performed immediately before and after CAS in 68 patients with and 175 without protection, and patients were further subdivided according to their age or symptom status. RESULTS The proportion of patients with new ipsilateral DWI lesion(s) was significantly lower after protected versus unprotected CAS (52% versus 68%), as well as in symptomatic patients (56% versus 74%) or those at or younger than 75 years of age (46% versus 67%; all P < .05). Similarly, the total number of lesions was significantly lower after protected versus unprotected CAS (median, 1; interquartile range [IQR], 0-2; versus median, 1; IQR 0-4.75) and in symptomatic patients (median, 1; IQR, 0-3; versus median, 2; IQR, 0-6) or those at or younger than 75 years of age (median, 0; IQR, 0-2; versus median, 1; IQR, 0-4; all P < .05). In contrast, for asymptomatic patients (48% versus 52%; P = .8; median, 0; IQR, 0-2; versus median, 1; IQR, 0-2.5; P = .6) or those older than 75 years of age (73% versus 69%; P = .7; median, 1; IQR, 0-4; versus median, 1.5; IQR, 0-5.75; P = .6), the proportion of patients with new lesion(s) and the total number of these lesions were not significantly different between protected and unprotected CAS. CONCLUSIONS The use of distal filter devices generally reduces the incidence of new DWI lesions; however, this beneficial effect might not necessarily pertain to older and asymptomatic patients.
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Affiliation(s)
- A Kastrup
- Department of Neurology, University of Göttingen, Göttingen, Germany.
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