Anatomical Modifications After Stent Implantation: A Comparative Analysis Between CGuard, Wallstent, and Roadsaver Carotid Stents

Carotid Artery Geometry Modifications and Clinical Implications after Carotid Artery Stenting

BACKGROUND

Carotid artery stenting (CAS) could lead to a modification of the carotid bifurcation geometry with possible clinical implications. This study aimed to clarify the geometrical impact of three carotid stents with different designs on the carotid bifurcation and its clinical consequences.

METHODS

This was a retrospective single-center study. We included all patients who underwent CAS in a 3-year period. Anatomical changes of the carotid bifurcation were evaluated by reviewing angiographic images. The population was divided into three groups based on the stent implanted: Group 1 (Carotid Wallstent), Group 2 (Roadsaver), and Group 3 (C-Guard).

RESULTS

A total of 226 patients were included. The mean age was 77.0 ± 7.4 years and 72.5% (164/226) were male. Three different stents were implanted into three groups: Group 1 (n = 131/226, 58%), Group 2 (n = 57/226, 25.2%), and Group 3 (n = 38/226, 16.8%). The mean pre-stent implantation CCA-ICA angle of the entire population was 155 ± 14.9°, and the post-CAS angle was 167.7 ± 8.7° (p = 0.0001). In every subgroup, the difference was statistically different, with the biggest difference registered in Group 2 (-16.1 ± 13.2°). Regarding stent oversizing, there was a significant relationship between CCA oversizing and CCA-ICA angle modification (p = 0.006). During follow-up, a total of 14 (6.2%) restenoses were registered. The mean CCA-ICA angle modification in the restenosis group was -9.5 ± 14.4° vs. -12.8 ± 11.9° in the no-restenosis group with no significant statistical differences were outlined (p = 0.3).

CONCLUSIONS

Compared to the Carotid Wallstent and C-Guard, the Roadsaver stent appears to have a lower adaptability to the carotid vascular territory, resulting in a higher CCA-ICA angle modification after implantation, with no impact on the stent restenosis rate.

Next-generation transcarotid artery revascularization: TransCarotid flOw Reversal Cerebral Protection And CGUARD MicroNET-Covered Embolic Prevention Stent System To Reduce Strokes - TOPGUARD Study

BACKGROUND

Stent-assisted carotid artery revascularization employing surgical cutdown for transcervical access and dynamic flow reversal (TCAR) is gaining popularity. TCAR, despite maximized intra-procedural cerebral protection, shows a marked excess of 30-day neurologic complications in symptomatic vs. asymptomatic stenoses. The TCAR conventional single-layer stent (free-cell area 5.89mm2) inability to seal embologenic lesions may be particularly relevant after the flow reversal neuroprotection is terminated.

METHODS

We evaluated peri-procedural and 30-day major adverse cerebral and cardiac events (MACCE) of TCAR (ENROUTE, SilkRoad Medical) paired with MicroNET-covered neuroprotective stent (CGuard, InspireMD) in consecutive patients at elevated risk of complications with transfemoral/transradial filter-protected stenting (increased lesion-related and/or access-related risk). CGuard (MicroNET free cell area ≈0.02-0.03 mm2) has level-1 evidence for reducing intra- and abolishing post-procedural lesion-related cerebral embolism.

RESULTS

One hundred and six increased-risk patients (age 72 [61-76] years, median [Q1-Q3]; 60.4% symptomatic, 49.1% diabetic, 36.8% women, 61.3% left-sided index lesion) were enrolled in three vascular surgery centers. Angiographic stenosis severity was 81 (75-91)%, lesion length 21 (15-26)mm, increased-risk lesional characteristics 87.7%. Study stent use was 100% (no other stent types). 74.5% lesions were predilated; post-dilatation rate was 90.6%. Flow reversal duration was 8 (5-11)min. One stroke (0.9%) occurred in an asymptomatic patient prior to establishing neuroprotection (index lesion disruption with the sheath insertion wire); there were no other peri-procedural MACCE. No further adverse events occurred by 30-days. 30-day stent patency was 100% with normal velocities and absence of any in-stent material by Duplex Doppler.

CONCLUSIONS

Despite a high proportion of increased-risk lesions and clinically symptomatic patients in this study, TCAR employing the MicroNET-covered anti-embolic stent showed 30-day MACCE rate <1%. This suggests a clinical role for combining maximized intra-procedural prevention of cerebral embolism by dynamic flow reversal with anti-embolic stent prevention of peri- and post-procedural cerebral embolism (TOPGUARD NCT04547387).

CIRSE Standards of Practice on Carotid Artery Stenting

BACKGROUND

Carotid artery stenting has been used effectively to treat internal carotid artery stenosis since 1989 (Mathias et al. in World J Surg. 25(3):328-34, 2001), with refined and expanded techniques and tools presently delivering outstanding results in percutaneous endoluminal treatment of carotid artery stenosis.

PURPOSE

This CIRSE Standards of Practice document is directed at interventional radiologists and details the guidelines for carotid artery stenting, as well as the different implementation techniques. In addition to updating all previously published material on the different clinical indications, it will provide all technical details reflective of European practice for carotid artery stenting. CIRSE Standards of Practice documents do not aim to implement a standard of clinical patient care, but rather to provide a realistic strategy and best practices for the execution of this procedure.

METHODS

The writing group, which was established by the CIRSE Standards of Practice Committee, consisted of five clinicians with internationally recognised expertise in carotid artery stenting procedures. The writing group reviewed existing literature on carotid artery stenting procedures, performing a pragmatic evidence search using PubMed to select relevant publications in the English language from 2006 to 2022.

RESULTS

Carotid artery stenting has an established role in the management of internal carotid artery stenosis; this Standards of Practice document provides up-to-date recommendations for its safe performance.

The role of post-dilatation in carotid MicroNet-covered stent implantation, evaluated using 3D cone-beam CT angiography

BACKGROUND

This study aims to assess the role and safety of post-dilatation in protected carotid artery stenting (PCAS) using the new MicroNet-covered 2nd-generation stent assessed by cone beam CT scans.

METHODS

From March 2020 to March 2022, patients were enrolled in the study according to CT angiography results based on the following criteria: Evidence of 70% to 99% carotid stenosis in asymptomatic patients and 50% to 99% in symptomatic patients, per the NASCET index. Using a FilterWire EZ™ (Boston Scientific, Natick, MA, USA) embolic protection system (EPS), MicroNet-covered stent PCAS was performed by two interventional radiologists with at least 8 years of experience in endovascular intervention. Each patient underwent post-dilatation following stent placement. Finally, a third radiologist (not participating in the interventional procedures) evaluated the cone beam CT scans and calculated residual stenosis. Major and minor complications were recorded in the 30 days following the procedure.

RESULTS

A total of 192 patients (121 male, mean age 73±10 years) were included in the study, and all patients received post-dilatation following stent implantation. Technical successes were achieved in all procedures. Adverse events noted in this study were limited to periprocedural transient ischemic attacks that occurred in three out of 192 patients (1.6%) and showed a swift complete recovery. The post-dilatation balloon diameters used in the study were: 5.0 mm (30.3%), 5.5 mm (39.3%) and 6 mm (30.3%). Optimized postdilatation resulted in a significant increase in the final luminal area. Similar improvements were observed in all subtypes of plaque.

CONCLUSIONS

Post-dilatation in protected CAS is safe and induces a significant improvement in the cross-sectional area regardless of the stenotic plaque.

Vascular surgery study of the CGuard MicroNet-covered stent in patients with indication to carotid revascularization: POLGUARD

BACKGROUND

In a recent randomized study, MicroNet-covered stent (CGuard) significantly reduced procedural and post-procedural cerebral embolism in relation to a single-layer CREST study carotid stent, but real-life clinical practice data are limited. The aim is to prospectively assess clinical outcomes of CGuard as a routine revascularization tool for patients with indication to carotid revascularization.

METHODS

From April 2019 to November 2021, 204 elective patients (age 71.0±7.1years, 69.6% males, 21.7% symptomatic) were enrolled.

RESULTS

Mean basal peak-systolic velocity was 251.41±91.85 cm/s with angiographic diameter stenosis 89.7±8.46%. About 34.4% lesions were severely calcified, 6.8% were angulated, and 4.4% showed significant access tortuosity. Access was femoral, with 100% protection device (filter) use. Two hundred and three lesions in 203 patients were treated (1 cross-over to surgery for lack of effective access, no cross-over to other devices); in most cases (66.9%) the stent was placed directly. For pre-dilated lesions, mean balloon diameter was 3.36±0.34mm. Mean nominal stent diameter was 7.64±0.5 mm; length was 37.19±4.5 mm. All stents were post-dilated (balloon diameter 5.2±0.25 mm). Residual stenosis was <30% in all (3.77±6.91%). By discharge, there were 2 minor strokes (0.9%) and one transient ischemic attack. By 30-days, one other minor stroke occurred in relation to de-novo atrial fibrillation. With no deaths or myocardial infarctions, 30-day total death/stroke/myocardial infarction rate was 1.48%. No in-stent thrombosis or patency loss occurred by 30-days. In-stent peak-systolic velocity was 55.49±22.73 cm/s.

CONCLUSIONS

Thirty-day results from POLGUARD study indicate safety and a low complication rate of the MicroNet-covered carotid stent use in every-day vascular surgery practice of carotid revascularization. Long-term observation is underway.