Cerebral Protection Devices Reduce Periprocedural Strokes During Carotid Angioplasty and Stenting:A Systematic Review of the Current Literature

Carotid artery stenting in unfavorable vascular anatomy: Effect of embolic protection filter use on periprocedural complications

OBJECTIVE

To investigate the effect of embolic protection device (EPD) use on periprocedural complications in patients with carotid artery stenosis with anatomical variations.

METHOD

The study retrospectively evaluated 185 patients who consecutively underwent carotid artery stenting between November 2020 and December 2023. Forty-four patients with difficult anatomical structures, anatomical variations in the common carotid artery (CCA) and internal carotid artery (ICA) (tortuosity, kinking, or coiling), and a CCA-ICA angle of >60 degrees were included in the sample. The patients were divided into two groups according to the use of EPD filters during the procedure and compared in terms of periprocedural events.

RESULTS

Of the 44 patients included in the study, 24 (54.5 %) were male, and the mean age of all patients was 68.7 ± 8.7 years. Comorbidities were present in 93.2 % (n = 41) of the patients. The most common comorbidity was hypertension (n = 32, 72.8 %). The CCA-ICA angle was ≥60 degrees in 45.4 % (n = 20) of all patients. ICA tortuosity was detected in 27.2 % (n = 12) of the patients, ICA kinking in 13.6 % (n = 6), ICA coiling in 6.8 % (n = 3), and CCA tortuosity in 6.8 % (n = 3). Procedure-related periprocedural events developed in 38.6 % (n = 17) of the patients. Postprocedural mortality occurred in two patients, secondary to myocardial infarction in one and COVID-19 pneumonia in the other. There was no significant difference between the filter and non-filter groups in relation to periprocedural events (p = 0.638). Major stroke did not occur in either group. Minor neurological events occurred in 15 % (n = 3/20) of the patients in the filter group and 16.7 % (n = 4/24) of those in the non-filter group. The incidence of vasospasm was statistically higher in patients using filters compared to those without filters (30 % vs. 0 %; P = 0.005, respectively).

CONCLUSION

Evaluation of vascular anatomy before carotid artery stenting is important to decide on the technical procedure to be applied in the procedure. The use of EPD in unfavorable anatomy does not reduce periprocedural neurological events. Instead, it results in technical difficulties, prolongs the duration of procedure, and leads to arterial vasospasm. Considering the high periprocedural events in this study, carotid endarterectomy may be a better alternative to endovascular treatment in patients with unfavorable carotid artery anatomy.

Transradial carotid artery stenting using double layer micromesh stent and novel post-dilation balloon with integrated embolic protection

OBJECTIVES

The highest rate of embolization during carotid artery stenting occurs during post-dilation. We evaluated the ability of the Paladin system (Contego Medical, Raleigh, NC), a novel PTA balloon with an integrated 40-ɥm pore filter, to collect microemboli that may pass into the cerebral circulation when used during post-dilation.

METHODS

25 symptomatic patients underwent transradial CAS using the Paladin system in conjunction with the Roadsaver (Terumo Corporation, Tokyo, Japan) micromesh stent. No additional embolic protection was used. The Paladin filters were collected following the procedure and preserved in formalin for histological analysis. The contents were evaluated for particle count and size. Subjects were followed for 30 days and evaluated for major cardiac adverse events (death, stroke and MI). Secondary endpoints included procedure success, device success, access site complications according to EASY score classification, major vascular or ischemic complications at follow up and in-stent restenosis rate evaluated with duplex ultrasound.

RESULTS

Mean age of patients was 68,5 years. Type 2 aortic arch was present in 77 % of patients and type 1 and type 3 in 12 % and 11 % of patients respectively. Procedural and device success was obtained in all cases without complications. The 30-day MAE rate was 0 %. Twenty-three filters underwent histological analysis. Microscopic debris was present in 100 % of filters, and 75 % of particles were less than 100ɥm in size. The mean number of particles per filter was 3352 ± 1567 (IQR 4300-2343), and the mean number of particles between 40-100ɥm per filter was 2499 ± 1240 (IQR 3227-1575).

CONCLUSION

CAS through radial approach can be safely and effectively performed using the IEP technology Paladin device and double-layer micromesh Roadsaver stent. This strategy can simplify the procedure and decrease peri-procedural complications and procedural time.

Embolic protection devices for carotid artery stenting: A network meta-analysis

OBJECTIVES

Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications.

METHODS

A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

RESULTS

Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups.

CONCLUSIONS

PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.

Fabrication of a monorail-type diagnostic catheter for rescue retrieval technique of a distal embolic protection device

In this technical report, we describe a challenging case concerning the retrieval of a distal embolic protection device (DEPD) post-carotid artery stenting. We propose a novel rescue retrieval technique for DEPD, employing a fabricated monorail-type HN5 diagnostic catheter. When integrated with existing strategies, this approach may optimize and streamline the process of DEPD removal.

Endovascular treatment for acute ischaemic stroke caused by isolated internal carotid artery occlusion: treatment strategies, outcomes, and prognostic factors

AIM

To describe the experience of endovascular treatment (EVT) of acute ischaemic stroke caused by isolated internal carotid artery (ICA) occlusion, with emphasis on treatment strategies, outcomes, and prognostic factors.

MATERIALS AND METHODS

A retrospective examination was performed of 66 consecutive patients with acute moderate-to-severe stroke who underwent EVT for isolated ICA occlusion from July 2016 to June 2021. The modified thrombolysis in cerebral ischaemia (mTICI) score was used to evaluate reperfusion outcomes. A multivariate analysis was performed to identify risk factors associated with poor 90-day outcome (modified Rankin Scale [mRS] 3-6).

RESULTS

The National Institutes of Health Stroke Scale (NIHSS) median score of the 66 patients at admission was 15. Twelve patients (18.2%) showed thrombus migration to the M1 segment or proximal M2 during EVT and underwent additional intracranial thrombectomy. Successful reperfusion (mTICI 2b-3) was achieved in 60 patients (90.9%) and complete reperfusion (mTICI 3) in 42 (63.6%). A poor functional outcome was seen in 27 patients (40.9%). The rate of 90-day mortality was 9.1% (6/66). Higher NIHSS scores and a lower Alberta Stroke Program Early CT Score (ASPECTS) were independently associated with poor outcomes. Complete reperfusion was the only treatment factor with a significant predictive value (adjusted odds ratio [OR] 0.03; 95% CI = 0.01 to 0.25; p=0.001).

CONCLUSION

Endovascular therapy is safe and effective in patients with acute ischaemic stroke due to isolated ICA occlusion. Prevention of thrombus migration and complete reperfusion should be the aim of EVT.

Distal embolic protection use during transfemoral carotid artery stenting is associated with improved in-hospital outcomes

OBJECTIVE

Despite current guidelines recommending the use of distal embolic protection during transfemoral carotid artery stenting (tfCAS) to prevent periprocedural stroke, there remains significant variation in the routine use of distal filters. We sought to assess in-hospital outcomes in patients undergoing tfCAS with and without embolic protection using a distal filter.

METHODS

We identified all patients undergoing tfCAS in the Vascular Quality Initiative from March 2005 to December 2021 and excluded those who received proximal embolic balloon protection. We created propensity score-matched cohorts of patients who underwent tfCAS with and without attempted placement of a distal filter. Subgroup analyses of patients with failed vs successful filter placement and failed vs no attempt at filter placement were performed. In-hospital outcomes were assessed using log binomial regression, adjusted for protamine use. Outcomes of interest were composite stroke/death, stroke, death, myocardial infarction (MI), transient ischemic attack (TIA), and hyperperfusion syndrome.

RESULTS

Among 29,853 patients who underwent tfCAS, 28,213 (95%) had a filter attempted for distal embolic protection and 1640 (5%) did not. After matching, 6859 patients were identified. No attempted filter was associated with significantly higher risk of in-hospital stroke/death (6.4% vs 3.8%; adjusted relative risk [aRR], 1.72; 95% confidence interval [CI], 1.32-2.23; P < .001), stroke (3.7% vs 2.5%; aRR, 1.49; 95% CI, 1.06-2.08; P = .022), and mortality (3.5% vs 1.7%; aRR, 2.07; 95% CI, 1.42-3.020; P < .001). In a secondary analysis of patients who had failed attempt at filter placement vs successful filter placement, failed filter placement was associated with worse outcomes (stroke/death: 5.8% vs 2.7%; aRR, 2.10; 95% CI, 1.38-3.21; P = .001 and stroke: 5.3% vs 1.8%; aRR, 2.87; 95% CI, 1.78-4.61; P < .001). However, there were no differences in outcomes in patients with failed vs no attempted filter placement (stroke/death: 5.4% vs 6.2%; aRR, 0.99; 95% CI, 0.61-1.63; P = .99; stroke: 4.7% vs 3.7%; aRR, 1.40; 95% CI, 0.79-2.48; P = .20; death: 0.9% vs 3.4%; aRR, 0.35; 95% CI, 0.12-1.01; P = .052).

CONCLUSIONS

tfCAS performed without attempted distal embolic protection was associated with a significantly higher risk of in-hospital stroke and death. Patients undergoing tfCAS after failed attempt at filter placement have equivalent stroke/death to patients in whom no filter was attempted, but more than a two-fold higher risk of stroke/death compared with those with successfully placed filters. These findings support current Society for Vascular Surgery guidelines recommending routine use of distal embolic protection during tfCAS. If a filter cannot be placed safely, an alternative approach to carotid revascularization should be considered.

Treatment results of carotid artery stenting in a developing country

OBJECTIVE

The purpose of this study was to investigate the details of minor complications of carotid artery stenting in a developing country.

METHODS

This was a retrospective, single-center study conducted on the target group consisting of 65 symptomatic patients who underwent carotid artery stenting. We assessed technical success rate, periprocedural complication within 30 days (hypotension, bradycardia, acute kidney injury, vasospasm, a transient ischemic attack, stroke, myocardial infarction, and death), and the differences between groups with and without complications.

RESULTS

Minor periprocedural complications occurred in 15 patients. In all, 8 (12.3%) had transient hypotension, 6 (9.2%) had bradycardia, 7 (10.7%) had acute kidney injury, 2 (3.1%) had vasospasm, and 1 (1.5%) had transient ischemic attack. A greater rate of minor complications was observed in women (p=0.051).

CONCLUSION

The results of the carotid artery stenting procedures performed in a developing country were acceptable.

Proximal versus distal protection: dissecting clinical trials

Carotid artery stenting (CAS) is a valid alternative to conventional carotid endarterectomy for treatment of carotid artery stenosis. Distal embolization of atherosclerotic debris causing cerebrovascular accidents during CAS has been the most significant concern limiting widespread application of CAS technology. A variety of embolic protection devices (EPDs) with different mechanism of action, have been designed to minimize the risk of major embolization causing stroke and their use is recommended by current guidelines. Two general types of EPDs are available: proximal protection devices (PPDs) and distal protection devices (DPDs). However, there is no convincing clinical evidence of the clinical superiority of one device over another. This review will examine the different types of available devices and also innovative devices and techniques, including strengths and weaknesses of each, and present the available evidence and rationale for their routine use during CAS.

The Safety and Long-Term Efficacy of Carotid Artery Stenting: An All-Comers Registry

Background Carotid artery stenting (CAS) has emerged as a less invasive alternative to carotid endarterectomy (CEA) for the prevention of future cerebrovascular events in patients with carotid artery stenosis. Despite multiple randomized controlled trials (RCTs) comparing CAS and CEA for carotid disease, real-world data outside the rigorous environment of trials is scarce. Methods The present study is a prospective observational study conducted at a tertiary care center, wherein all patients who underwent CAS between January 2007 and December 2019 were included. All patients were followed up for one year of the last enrolled patient at an interval of one, six, and 12 months and then yearly thereafter. The primary composite outcome was defined as a combination of periprocedural (until 30 days of procedure) major adverse cardiac and cerebrovascular events (MACCEs) and the long-term incidence of ipsilateral stroke. The secondary outcome included the rate of restenosis. Results A total of 115 patients (86 males and 29 females) (147 lesions) who underwent CAS between 2007 and 2019 were followed up for a median of 80.5 months. Seventy-seven (67.27%) patients were symptomatic, and 38/115 (33%) were asymptomatic. Periprocedural MACCEs were noted in six patients, and four patients had ipsilateral stroke on long-term follow-up; hence, the primary composite outcome was observed in 10 (8.7%) patients. Higher age was found to be significantly associated with the primary composite outcome (p-value = 0.005). Five (4.34%) patients were lost to follow-up, while four (3.48%) patients developed restenosis. Conclusion CAS is a safe and less invasive intervention in patients with significant carotid artery stenosis and is equally effective in preventing future strokes. The incidence of primary outcome rises with an increase in age.

Protected carotid artery stenting in patients with severe stenosis

Intraplaque hemorrhage (IPH) and ulcers are the major findings of unstable plaques. In addition, initial symptoms are associated with postprocedural complications after carotid artery stenting (CAS). The aim of this study was to determine the safety of CAS using an embolic protection device in symptomatic patients with severe carotid artery stenosis and unstable plaques such as IPH and ulcers. This retrospective study included 140 consecutive patients with severe carotid stenosis. These patients underwent preprocedural carotid vessel wall imaging to evaluate the plaque status. We analyzed the incidence of initial clinical symptoms, such as headache, nausea, and vomiting, after CAS. The primary outcomes analyzed were the incidence of stroke, myocardial infarction, and death within 30 days of CAS. Sixty-seven patients (47.9%) had IPH, and 53 (38.9%) had ulcers on carotid wall imaging/angiography. Sixty-three patients (45.0%) had acute neurological symptoms with positive diffusion-weighted image findings. Intraluminal thrombi on initial angiography and flow arrest during CAS were significantly higher in patients with IPH and symptomatic patients. Symptoms were significantly higher in patients with IPH than in those without (63.5% vs 35.1%, P < .001). There were no significant differences in clinical symptoms after stenting or in primary outcomes, regardless of IPH, ulcer, or initial symptoms. IPH and plaque ulceration are risk factors in symptomatic carotid stenosis. However, IPH and plaque ulceration were not a significant risk factors for cerebral embolism during protected carotid artery stent placement in patients with carotid stenosis. Protected CAS might be feasible and safe despite the presence of unstable plaques.

Non-protected carotid artery stenting for symptomatic carotid stenosis in low resource settings

Background

The use of a distal cerebral protection device during extracranial carotid artery stenting is still a matter of debate. The aim of this work was to evaluate the safety of performing carotid artery stenting procedure without the use of cerebral protection device in patients with symptomatic carotid stenosis. A retrospective study was performed during the period from September 2015 till March 2020 including 91 patients with symptomatic carotid artery stenosis. All patients were treated with a single stent type (Wall stent® - Boston scientific) without the use of cerebral protection device. Pre- and post-procedural clinical assessment with the national institute of health stroke scale (NIHSS). Post procedure brain diffusion-weighted magnetic resonance imaging (DW-MRI) if clinically indicated within 24 h was used to determine periprocedural cerebral embolization.

Results

A low complication rate was found as only one case (1%) showed mild deterioration in NIHSS and new acute cerebral emboli were detected with brain DW-MRI.

Conclusion

Carotid artery stenting can be performed safely without the use of cerebral protection device.

CaRotid Artery Filtering Technique (CRAFT): A Technique for Carotid Artery Stenting with Intrinsic Embolic Protection

Purpose

Carotid artery stenting (CAS) is an established treatment for symptomatic carotid artery stenosis as an alternative to carotid endarterectomy. A variety of techniques and devices have been devised to minimise periprocedural stroke risk using either proximal or distal embolic protection. This study presents a method of embolic protection during CAS–the CaRotid Artery Filtering Technique (CRAFT).

Materials and Methods

The CRAFT technique employs aspects of both proximal and distal embolic protection. The CASPER RX stent (MicroVention, Tustin, CA, USA), which is a double-layered, closed-cell, micromesh nitinol stent, is deployed across the carotid artery stenosis with the assistance of a FlowGate balloon guide catheter (Stryker Neurovascular, Fremont, CA, USA). The partially deployed stent acts as a distal filter while the balloon guide is deflated midway during stent deployment to prevent distal plaque embolisation, followed by completion of stent deployment and angioplasty.

Results

A total of 94 patients underwent CAS using the CRAFT technique between June 2016 and March 2021. Successful stent deployment was achieved in all patients. Preliminary results demonstrated acute stent occlusion in 6 patients (6.4%) and distal embolic stroke in 5 patients (5.3%). The median procedural fluoroscopy time was 34 minutes with an interquartile range of 22 to 55 minutes.

Conclusion

The CRAFT technique of CAS presented by this study can be applied in the treatment of symptomatic carotid artery stenosis in both emergency and elective procedure settings with a high technical success and low distal embolic stroke risk.

Transcervical carotid artery revascularization: A systematic review and meta-analysis of outcomes

OBJECTIVE

Carotid artery stenosis is considered a determinant factor for cerebrovascular events, estimated to be the cause of 10% to 20% of all ischemic strokes. Transcervical carotid artery revascularization (TCAR) has been offered as an alternative to transfemoral carotid artery stenting and carotid endarterectomy to treat carotid artery stenosis.

METHODS

We performed a systematic review and meta-analysis of prospective and retrospective studies reporting the outcomes of patients who had undergone TCAR for carotid artery stenosis. The incidence of periprocedural adverse events was calculated.

RESULTS

A total of 45 studies with 14,588 patients met the predefined eligibility criteria and were included in the present meta-analysis. The technical success rate was 99% (95% confidence interval [CI], 98%-99%). The reasons for technical failure included an inability to cross the lesion and/or failure to deploy the stent. Access site complications occurred in 2% of all cases (95% CI, 1%-2%; 30 studies). Overall, the incidence of cranial nerve (CN) injuries was very rare, with only 33 of 8994 patients experiencing neurologic deficits attributed to CN involvement. Bleeding complications were reported by 20 studies and occurred in 2% (95% CI, 1%-3%) of all cases. The overall periprocedural all-cause mortality and stroke rate was 0.5% and 1.3%, respectively. In-stent restenosis was observed in 4 of 260 patients (1.5%; 7 studies), and early (30-day) reocclusion or acute thrombosis of the target lesion occurred in 12 of 1243 patients (∼1%; 11 studies).

CONCLUSIONS

The results from the present study have provided significant evidence that TCAR is a very promising and safe carotid revascularization approach with favorable technical success rates associated with low periprocedural stroke and CN injury rates.

Carotid Stenting without Embolic Protection Increases Major Adverse Events: Analysis of the National Surgical Quality Improvement Program

BACKGROUND AND PURPOSE

Published data regarding embolic protection device efficacy is mixed, and its use during carotid artery stent placement remains variable. We, therefore, examined the frequency of embolic protection device use and its association with outcomes after carotid artery stent placement using a national quality improvement data base.

MATERIALS AND METHODS

Patients undergoing carotid artery stent placement with or without embolic protection devices were identified in the American College of Surgeons National Surgical Quality Improvement Program data base. The primary outcome was the incidence of major adverse cardiovascular events (defined as death, stroke, or myocardial infarction/arrhythmia) within 30 days. Propensity scoring was used to create 2 matching cohorts of patients using demographic and baseline variables.

RESULTS

Between 2011 and 2018, among 1200 adult patients undergoing carotid artery stent placement, 23.8% did not have embolic protection devices. There was no trend toward increased embolic protection device use with time. Patients without embolic protection device use received preoperative antiplatelets less frequently (90.6% versus 94.6%, P = .02), underwent more emergent carotid artery stent placement (7.2% versus 3.6%, P = .01), and had a higher incidence of major adverse cardiovascular events (OR = 1.81; 95% CI, 1.11-2.94) and stroke (OR = 3.31; 95% CI, 1.71-6.39). After compensating for baseline imbalances using propensity-matched cohorts (n = 261 for both), carotid artery stent placement without an embolic protection device remained associated with increased major adverse cardiovascular events (9.2% versus 4.2%; OR = 2.30; 95% CI, 1.10-4.80) and stroke (6.5% versus 1.5%; OR = 4.48; 95% CI, 1.49-13.49).

CONCLUSIONS

Lack of embolic protection device use during carotid artery stent placement is associated with a 4-fold increase in the likelihood of perioperative stroke. Nevertheless, nearly one-quarter of patients in the American College of Surgeons National Surgical Quality Improvement Program underwent unprotected carotid artery stent placement. Efforts targeting improved embolic protection device use during carotid artery stent placement are warranted.

Is it possible to prevent cerebral embolization by improving the design and technology of carotid stent implantation?

INTRODUCTION

The prevention of atherosclerotic plaque fragmentation during carotid artery stenting is a fundamental problem in decreasing the risk of disability of patients. The goal of this review is to clarify whether the stent design can have a decisive impact on the rate of intraoperative and postoperative complications.

AREAS COVERED

Different designs of the carotid stents are briefed and the advantages and disadvantages of different stent designs are discussed as well as the results of their clinical use. Various solutions are presented to reduce cerebral embolism during carotid artery stenting.

EXPERT OPINION

There is no conclusive evidence for the benefits of closed cell and hybrid stents. The stent design cannot completely resolve the problem of cerebral embolism. Most of the events of cerebral microembolism occur at the stages of stent delivery rather than protrusion of an atherosclerotic plaque in the long-term follow-up. Most likely, minimization of the risks for periprocedural and postprocedural strokes requires not only the new solutions in stent design as well as the corresponding delivery systems and brain embolic protection systems, but also the new strategies of preprocedural drug stabilization of the atherosclerotic plaque in the carotid artery. Abbreviations: CAS, carotid artery stenting; CE, carotid endarterectomy; DW-MRI, diffusion-weighted magnetic resonance imaging; ECA, external carotid artery; ICA, internal carotid artery; IVUS, intravascular ultrasound examination; OCT, optical coherence tomography.

Clinical study of stent forming for symptomatic internal carotid artery stenosis

Stroke is one of the diseases that seriously threaten the survival and health of human beings. In Europe and the United States, stroke is the second leading cause of death after heart disease and tumors. Stroke is also one of the fatal diseases in Asian countries. On average, about 1.5 million new stroke patients are added each year in China, and the incidence of stroke is increasing year by year. About 80% of all stroke patients are ischemic stroke, and symptomatic internal carotid atherosclerotic stenosis is another important cause of ischemic stroke. Ipsilateral carotid stenosis ≥50% increases the incidence of transient cerebral ischemia and stroke in the carotid artery region by 10% to 15%, and is also closely related to the recurrence of acute and long-term stroke in patients. Therefore, the clinical application and efficacy of carotid stenting in patients with symptomatic internal carotid artery stenosis are analyzed and evaluated to provide a basis for the selection of clinical treatment options.The clinical data of patients with symptomatic carotid stenosis who underwent carotid stenting and the clinical data of conservative treatment of patients with symptomatic carotid stenosis were retrospectively analyzed, and the carotid stenosis rate, symptoms, and National Institute of Health stroke scale where compared before and after surgery. And activities of daily living score. Because the control group treatment method in this article is completely free for patients to choose, and belongs to a retrospective analysis, the results suggest that it can provide a high-quality treatment approach for the treatment of patients with symptomatic carotid stenosis, without causing any harm to the patient, So no ethical approval is needed, and no patient informed consent is required.In recent years, with the continuous advancement of science and technology and new stent materials, intravascular interventional technology has developed rapidly. In continuous clinical practice and research, the safety and effectiveness of stent technology have also been gradually improved. Arterial stenting has gradually become an important method for the treatment of atherosclerotic carotid stenosis. This technique can not only improve the symptoms and prognosis of patients with symptomatic internal carotid stenosis, but also prevent the occurrence of ischemic events. The promotion of this technology has the effect of reducing disability and mortality.The alternative therapy of drug therapy, namely arterial stent implantation, has become a new way to treat atherosclerotic stroke. This treatment technology can quickly relieve the abnormal hemodynamics of distal blood vessels caused by arterial stenosis, which is ischemic. Cerebrovascular disease provides new ideas for treatment. Carotid angioplasty and stenting for symptomatic internal carotid stenosis under a distal cerebral protection device is a safe and effective treatment.

Carotid Revascularization: Current Practice and Future Directions

Carotid stenosis is responsible for approximately 15% of ischemic strokes. Carotid revascularization significantly decreases patients' stroke risk. Carotid endarterectomy has first-line therapy for moderate-to-severe carotid stenosis after a series of pivotal randomized controlled trials were published almost 30 years ago. Revascularization with carotid stenting has become a popular and effective alternative in a select subpopulation of patients. We review the current state of the literature regarding revascularization indications, patient selection, advantages of each revascularization approach, timing of intervention, and emerging interventional techniques, such as transcarotid artery revascularization.

WIRION™ embolic protection system for carotid artery stenting and lower extremity endovascular intervention

Aim: To summarize all available literature regarding the Wirion™ embolic protection system (EPS) and present examples from our center. Materials & methods: A review of literture was performed about the utilization of Wirion EPS. Results: One study was identified investigating the outcomes of Wirion during carotid artery stenting. The study demonstrated 98.3% procedural success with stroke occurring in only 2.5%. Two single arm studies were identified investigating the efficacy of the Wirion filter during lower extremity endovascular interventions. The reported device success ranged from 95.1 to 97.3%. Conclusion: While carotid artery stenting should always be performed with adjunctive EPS in order to decrease the risk of cerebrovascular accidents, the routine use of EPS in femorpopliteal interventions remains an active area of investigation.

Propensity-Matched Outcomes of Transcarotid Artery Revascularization Versus Carotid Endarterectomy

BACKGROUND

Transcarotid artery revascularization (TCAR) with cerebral flow reversal is an emerging treatment option for carotid artery stenosis in patients with high risk for traditional endarterectomy. The purpose of this study was to compare real-world, procedure-related outcomes in similarly comorbid patients undergoing TCAR or carotid endarterectomy (CEA).

METHODS

A retrospective review of all patients receiving either TCAR or CEA outside of clinical trial regulations at our institution was performed. Participants were propensity-matched by age, gender, body mass index, smoking status, presence of restenosis, history of neck radiation, presence of contralateral carotid occlusion, history of previous neck dissection, and symptom status. Bivariate analysis was followed by a penalized Firth logistic regression to compare treatments.

RESULTS

Between January 2011 and July 2018, 342 CEAs and 109 TCARs were captured for analysis. After matching, 87 distinct treatment pairs were created without evidence of variation in any of the prespecified variables. On multivariate analysis using maximum and penalized likelihood ratios, we found that TCAR was associated with an increased incidence of intraoperative hypertension (adjusted coefficient, 1.41; 95% confidence interval [0.53, 2.29], P < 0.01). TCAR was also associated with decreased reverse flow/clamp time (mins; -36.80; [-45.47, -27.93], P < 0.01) and estimated blood loss (mLs; -63.66; [-85.91, -41.42], P < 0.01). In the perioperative period, there were no differences between TCAR and CEA with respect to myocardial infarction (-0.04; [-3.68, 3.60], P = 0.98), stroke (-0.74; [-2.68, 1.19], P = 0.45), and all-cause mortality (1.09; [-1.76, 3.94], P = 0.11). Similarly, a composite incidence of stroke/death was the same between cohorts (2.42; [-0.57, 5.41], P = 0.11).

CONCLUSIONS

This propensity-matched analysis of carotid artery revascularization modalities suggests that TCAR is equivalent to CEA in the perioperative period while incurring shorter operative time and less blood loss.

Lower Rate of Restenosis and Reinterventions With Covered vs Bare Metal Stents Following Innominate Artery Stenting

Purpose: To determine any difference between bare metal stents (BMS) and balloon-expandable covered stents in the treatment of innominate artery atheromatous lesions. Materials and Methods: A multicenter retrospective study involving 13 university hospitals in France collected 93 patients (mean age 63.2±11.1 years; 57 men) treated over a 10-year period. All patients had systolic blood pressure asymmetry >15 mm Hg and were either asymptomatic (39, 42%) or had carotid (20, 22%), vertebrobasilar (24, 26%), and/or brachial (20, 22%) symptoms. Innominate artery stenosis ranged from 50% to 70% in 4 (4%) symptomatic cases and between 70% and 90% in 52 (56%) cases; 28 (30%) lesions were preocclusive and 8 (9%) were occluded. One (1%) severely symptomatic patient had a <50% stenosis. Demographic characteristics, operative indications, and procedure details were compared between the covered (36, 39%) and BMS (57, 61%) groups. Multivariate analysis was performed to determine relative risks of restenosis and reinterventions [reported with 95% confidence intervals (CI)]. Results: The endovascular procedures were performed mainly via retrograde carotid access (75, 81%). Perioperative strokes occurred in 4 (4.3%) patients. During the mean 34.5±31.2–month follow-up, 30 (32%) restenoses were detected and 13 (20%) reinterventions were performed. Relative risks were 6.9 (95% CI 2.2 to 22.2, p=0.001) for restenosis and 14.6 (95% CI 1.8 to 120.8, p=0.004) for reinterventions between BMS and covered stents. The severity of the treated lesions had no influence on the results. Conclusion: Patients treated with BMS for innominate artery stenosis have more frequent restenoses and reinterventions than patients treated with covered stents.

Technical improvements in carotid revascularization based on the mechanism of procedural stroke

The benefit of carotid revascularization in patients with severe carotid artery stenosis is hampered by the risk of stroke due to the intervention itself. The risk of periprocedural strokes is higher for carotid artery stenting (CAS) as compared to carotid endarterectomy (CEA). Over the past years, the pathophysiological mechanism responsible for periprocedural stroke seems to unfold step by step. Initially, all procedural strokes were thought to be the result of technical errors during surgical repair: cerebral ischemia due to clamping time of the carotid artery, cerebral embolization of atherosclerotic debris due to manipulation of the atheroma or thrombosis of the artery. Following improvements in surgical techniques, technical skills, new intraoperative monitoring technologies such as angioscopy, and the results of the first large clinical randomized controlled trials (RCT) it was believed that most periprocedural strokes were of thromboembolic nature, while a large part of these caused by technical error. Nowadays, analyses of underlying pathophysiological mechanisms of procedural stroke make a clinically relevant distinction between intra-procedural and postprocedural strokes. Intra-procedural stroke is defined as hypoperfusion due to clamping (CEA) or dilatation (CAS) and embolization from the carotid plaque (both CEA and CAS). Postprocedural stroke can be caused by thrombo-embolisation but seems to have a primarily hemodynamic origin. Besides thrombotic occlusion of the carotid artery, cerebral hyperperfusion syndrome (CHS) due to extensively increased cerebral revascularization is the most reported pathophysiological mechanism of postprocedural stroke. Multiple technical improvements have attempted to lower the risk of periprocedural stroke. The introduction of antiplatelet therapy (APT) has significantly reduced the risk of thromboembolic events in patients with carotid stenosis. Over the years, recommendations regarding APT changed. While for a long time APT was discontinued prior to surgery because of a fear of increased bleeding risk, nowadays continuation of APT during carotid intervention (aspirin monotherapy or even dual APT including clopidogrel) is found to be safe and effective. In CAS patients, dual APT up to three months' postprocedural is considered best. Stent design and cerebral protection devices (CPD) for CAS procedure are continuously under development. Trials have suggested a benefit of closed-cell stent design over open-cell stent design in order to reduce procedural stroke, while the benefit of CPD during stenting is still a matter of debate. Although CPD reduce the risk of procedural stroke, a higher number of new ischemic brain lesions detected on diffusion weighted imaging was found in patients treated with CPD. In patients undergoing CEA under general anesthesia, adequate use of cerebral monitoring (EEG and transcranial Doppler [TCD]) has reduced the number of intraoperative stroke by detecting embolization and thereby guiding the surgeon to adjust his technique or to selectively shunt the carotid artery. In addition, TCD is able to adequately identify and exclude patients at risk for CHS. For CAS, the additional value of periprocedural cerebral monitoring to prevent strokes needs urgent attention. In conclusion, this review provides an overview of the pathophysiological mechanism of stroke following carotid revascularization (both CAS and CEA) and of the technical improvements that have contributed to reducing this stroke risk.

Carotid artery stenting in a single center, single operator, single type of device and 15 years of follow-up

Background

Revascularization with carotid stent (CAS) is considered the therapeutic alternative to endarterectomy (CEA). However, its role compared to CEA remains questioned, mainly due of the heterogeneity of long-term results. The objective of this study was to report the efficacy and durability of CAS in terms of stroke prevention in a "real world experience".

Method

This was a single-center retrospective analysis of 344 patients treated with CAS between January 2001 and December 2015.The primary outcome of the trial was stroke, myocardial infarction, or death during a periprocedural period or any stroke event over a 15-year follow-up. The secondary aim was to identify risk factors for 30-day complications, long-term neurological complications, and intra-stent restenosis.

Results

The primary composite end point (any stroke, myocardial infarction, or death during the periprocedural period) was 2.3%. The use of an EPD was protective against major complications.Long-term follow-up was achieved in 294 patients (85,5%) with a median of 50 months (range 0-155 months). Fifty-six (16,3%) died within this period, most commonly of nonvascular causes (4 patients had stroke-related deaths). During the follow-up period, 8 strokes and 3 TIAs were diagnosed (3.2%).ISR determined by sequential ultrasound was assessed in 4.4% of the patients and remained asymptomatic in all but 2 patients (0.6%). All patients with restenosis underwent revascularization with balloon angioplasty.

Conclusion

The long-term follow-up results of our study validate CAS as a safe and durable procedure with which to prevent ipsilateral stroke, with an acceptable rate of restenosis, recurrence and mortality.

Invasive treatment in peripheral artery disease

Invasive treatment in peripheral artery disease (PAD) has evolved as a viable alternative to surgical treatment. However, beyond the common pathophysiological substrate, as far as treatment is concerned, each site of atherosclerotic disease (subclavian and vertebral arteries; carotid arteries; intracranial arterial tree; renal arteries; lower extremity arteries) features unique characteristics. Treatment options include medical treatment, endovascular management and/or surgery. Sound clinical evaluation is required as individual patient assessment often limits intervention options, while available data regarding benefits of invasive and surgical management are questioned by advances in medical treatment. In the present article, we aim to summarize existing evidence and guidance on the role of invasive procedures in PAD.

Staged carotid artery stenting in patients with severe carotid stenosis: Multicenter experience

Cerebral hyperperfusion syndrome (CHS) is serious complication after carotid artery stenting (CAS) caused by decreased cerebral vasoreactivity (CVR) due to long standing hypoperfusion of the brain. We hypothesized that partial dilatation of carotid stenosis would allow the recovery of CVR, and prevent CHS when definitive angioplasty with stent is performed afterward. In this study, we aimed to evaluate the safety and efficacy of staged CAS in patients with severe carotid artery stenosis with evident hemodynamic compromise in regard to preventing hyperperfusion syndrome. From January 2005 to February 2016, 53 patients with 55 severe carotid artery stenosis lesions showing decreased CVR and/or cerebral basal flow at the perfusion studies underwent staged CAS in three institutes. The procedure consisted of initial partial balloon angioplasty (BA), recovery period, and delayed definitive stenting (DS). We analyzed immediate results, complications, recoil and CHS related to staged CAS. We experienced no symptomatic manifestation of CHS except self-limited headache after the procedures. The median of intervals between BA and DS stages were 10 days. There was no case of severe recoil during the interval between BA and DS stage. Where perfusion imaging data was available, hyperperfusion was present in three and one patients after BA and DS stage, respectively, with no clinical symptom of CHS. In conclusion, staged CAS was feasible in patients with severe carotid artery stenosis and hemodynamic compromise, without inducing severe complication of CHS such as intracranial hemorrhage.

Protected versus Unprotected Carotid Artery Stenting : Meta-Analysis of the Current Literature

Objective

To compare peri-operative any symptomatic stroke after carotid angioplasty and stenting (CAS), based on the application or absence of a cerebral protection device.

Methods

A systematic literature review using PubMed, Embase, and the Cochrane Central was done across an online data base from January 1995 to October 2016. Procedures which were performed due to carotid dissection or aneurysm, procedures using covered stents or conducted in an emergency, were excluded. The primary endpoint was perioperative any symptomatic stroke within 30 days after the procedure. A fixed effect model was used in cases of heterogeneity less than 50%.

Results

In the 25 articles included in this study, the number of stroke events was 326 (2.0%) in protected CAS and 142 (3.4%) in unprotected CAS. The use of cerebral protection device significantly decreased stroke after CAS (odds ratio [OR] 0.633, 95% confidence interval [CI] 0.479–0.837, p=0.001). In the publication bias analysis, Egger’s regression test disclosed that the intercept was -0.317 (95% CI -1.015–0.382, p=0.358). Regarding symptomatic patients (four studies, 539 CAS procedures), the number of stroke was six (1.7%) in protected CAS and 11 (5.7%) in unprotected CAS. The protective effect against stroke events by cerebral protection device did not have a statistical significance (OR 0.455, 95% CI 0.151–1.366, p=0.160).

Conclusion

The use of protection device significantly decreased stroke after CAS. However, its efficacy was not demonstrated in symptomatic patients. Routine use of protection device during CAS should be critically assessed before mandatory use.

The Use of Embolic Protection Devices Is Associated With a Lower Stroke and Death Rate After Carotid Stenting

OBJECTIVES

The aim of this study was to analyze the association between intraprocedural and periprocedural variables and in-hospital stroke or death rate after carotid artery stenting.

BACKGROUND

In Germany, all open surgical and endovascular procedures on the extracranial carotid artery must be documented in a statutory nationwide quality assurance database.

METHODS

A total of 13,086 carotid artery stenting procedures for asymptomatic (63.9%) or symptomatic carotid stenosis (mean age 69.7 years, 69.7% men) between 2009 and 2014 were recorded. The following variables were analyzed: stent design, stent material, neurophysiological monitoring, periprocedural antiplatelet medication, and use of an embolic protection device. The primary outcome was in-hospital stroke or death. Major stroke or death, any stroke, and death, all until discharge, were secondary outcomes. Adjusted relative risks (RRs) were assessed using multilevel multivariable regression analyses.

RESULTS

The primary outcome occurred in 2.4% of the population (1.7% in asymptomatic and 3.7% in symptomatic patients). The multivariable analysis showed an independent association between the use of an embolic protection device and lower in-hospital rates of stroke or death (adjusted RR: 0.65; 95% confidence interval [CI]: 0.50 to 0.85), major stroke or death (adjusted RR: 0.60; 95% CI: 0.43 to 0.84), and stroke (adjusted RR: 0.57; 95% CI: 0.43 to 0.77). Regarding the occurrence of in-hospital death, there was no significant association (adjusted RR: 0.78; 95% CI: 0.46 to 1.35). None of the outcomes was associated with stent design, stent material, neurophysiological monitoring, or antiplatelet medication.

CONCLUSIONS

The use of an embolic protection device was independently associated with lower in-hospital risk for stroke or death, major stroke or death, and stroke.

Carotid Artery Stenting

Carotid artery stenosis is relatively common and is a significant cause of ischemic stroke, but carotid revascularization can reduce the risk of ischemic stroke in patients with significant symptomatic stenosis. Carotid endarterectomy has been and remains the gold standard treatment to reduce the risk of carotid artery stenosis. Carotid artery stenting (CAS) (or carotid artery stent implantation) is another method of carotid revascularization, which has developed rapidly over the last 30 years. To date, the frequency of use of CAS is increasing, and clinical outcomes are improving with technical advancements. However, the value of CAS remains unclear in patients with significant carotid artery stenosis. This review article discusses the basic concepts and procedural techniques involved in CAS.

Proximal embolic protection versus distal filter protection versus combined protection in carotid artery stenting: A systematic review and meta-analysis

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.

Meta-analysis of the procedural risks of carotid endarterectomy and carotid artery stenting over time

Background

Stroke/death rates within 30 days of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in RCTs inform current clinical guidelines. However, the risks may have changed in recent years with wider use of effective stroke prevention therapies, especially statins, improved patient selection and growing operator expertise. The aim of this study was to investigate whether the procedural stroke/death risks from CEA and CAS have changed over time.

Methods

MEDLINE and Embase were searched systematically from inception to May 2016 for observational cohort studies of CEA and CAS. Studies included reported on more than 1000 patients, with 30‐day outcomes after the procedure according to patients' symptom status (recent stroke or transient ischaemic attack). Restricted maximum likelihood random‐effects and meta‐regressions methods were used to synthesize procedural stroke/death rates of CEA and CAS according to year of study recruitment completion.

Results

Fifty‐one studies, including 223 313 patients undergoing CEA and 72 961 undergoing CAS, were reviewed. Procedural stroke/death risks of CEA decreased over time in symptomatic and asymptomatic patients. Risks were substantially lower in studies completing recruitment in 2005 or later, both in symptomatic (5·11 per cent before 2005 versus 2·68 per cent from 2005 onwards; P = 0·002) and asymptomatic (3·17 versus 1·50 per cent; P < 0·001) patients. Procedural stroke/death rates of CAS did not change significantly over time (4·77 per cent among symptomatic and 2·59 per cent among asymptomatic patients). There was substantial heterogeneity in event rates and recruitment periods were long.

Conclusions

Risks of procedural stroke/death following CEA appear to have decreased substantially. There was no evidence of a change in stroke/death rates following CAS.

Endarterectomy outcomes improving

Endovascular management of extracranial occlusions at the hyperacute phase of stroke with tandem occlusions

BACKGROUND AND PURPOSE

The management of cervical artery occlusions in hyperacute stroke with tandem cervical/intracranial occlusions has not yet become standardized, especially when the circle of Willis is effective.

METHODS

We retrospectively analyzed the safety and accuracy of current approaches to manage the cervical occlusion in consecutive patients with tandem occlusions addressed for intracranial mechanical thrombectomy (MT) in our department from January 2012 to May 2017. The different approaches that could be performed in a same patient during the same procedure or hospitalization were analyzed separately.

RESULTS

We reported 64 approaches to manage the cervical occlusion in 49 patients with tandem occlusion (14% of MT): medical treatment alone in 16/64 (25%), stenting/angioplasty in 16/64 (25%), occlusion with coils in 12/64 (19%), angioplasty alone in 9/64 (14%), stent-retriever in 8/64 (12%), and/or thromboaspiration in 3/64 (5%). Early ipsilateral embolic recurrence occurred after 9/64 (14%) of them. It was strongly associated with the presence of a cervical intraluminal thrombus (P=0.001) and was then lower after occlusion with coils and stent-retriever compared to medical treatment alone and thromboaspiration (P=0.002). Occlusion with coils had a lower rate of radiological intracranial hemorrhage at 48-hour compared to other approaches (P=0.009). The 3-month rates of favorable outcome (P=0.806) and mortality (P=0.878) were similar. One delayed stroke was imputable to an occlusion with coils, for a median (Q1-Q3) follow-up of 10 (3-20) months.

CONCLUSIONS

Cervical occlusion with coils and thrombectomy with stent-retrievers may be relevant to prevent early embolic recurrence in cervical occlusions with intraluminal thrombus. Stent-retrievers should be further assessed as a first-line approach, since delayed stroke may occur following occlusion with coils. Medical treatment alone may be sufficient when no cervical intraluminal thrombus is present, the Willis polygon is effective, and the cervical occlusion can be crossed easily to perform the intracranial thrombectomy.

Independent Modular Filter for Embolic Protection in Carotid Stenting

BACKGROUND

Embolic protection during carotid artery stenting reduces the rate of thromboembolic events. The Wirion Embolic Protection System is used to deploy an independent distal filter using any 0.014″ guidewire. WISE study (Wirion Study Europe) evaluated the safety and performance of Wirion Embolic Protection System in patients undergoing carotid artery stenting.

METHODS AND RESULTS

A prospective, multicenter, nonrandomized, open-label, single-arm study of carotid artery stenting in high surgical risk patients was performed. The primary end point, a composite of death, stroke, and myocardial infarction at 30 days, was compared with performance goal derived from historical controls. Secondary end points were components of the primary end point and the device, angiographic, procedural, and clinical success rates. Preplanned interim analysis was performed on the first 120 patients. At interim analysis, the primary end point was significantly lower for the Wirion Embolic Protection System group, compared with historical data (3.3% versus 6.3%, respectively; P value =0.0008). Analysis of primary end point components in the WISE group, compared with the historical control group, shows numerically lower mortality (0% versus 1.7%, respectively; P=0.21), stroke (2.5% versus 4.6%, respectively; P=0.18), and myocardial infarction (0.8% versus 1.5%, respectively; P=0.50). Device, angiographic, procedural, and clinical success was achieved in 99.2%, 99.1%, 98.3%, and 96.6% of cases, respectively.

CONCLUSIONS

The data suggest that independent modular filter use in carotid artery stenting in high surgical risk patients is safe and effective. The outcomes suggest that use of an independent modular filter may be associated with a lower rate of embolic complications associated with carotid stent placement.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01783639.

Proximal balloon occlusion versus distal filter protection in carotid artery stenting: A meta-analysis and review of the literature

INTRODUCTION

Carotid artery stenting (CAS) is typically performed using embolic protection devices (EPDs) as a means to reduce the risk of procedure-related stroke. In this study, we compared procedural morbidity and mortality associated with distal (D-EPD) vs. proximal (P-EPD) protection.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1998 through May 2015. Only studies comparing (D-EPD) and (P-EPD) were included. Two independent reviewers selected and appraised studies and extracted data in duplicate. Random-effects meta-analysis was used to pool outcomes across studies. Heterogeneity of treatment effect among studies was assessed using the I² statistics. Publication bias was assessed using inspection of funnel plots. The primary endpoints included 30-day mortality and stroke. Secondary endpoints included new cerebral lesions on diffusion-weighted magnetic resonance imaging (DW-MRI) and contralateral lesions on DW-MRI.

RESULTS

A total of 12,281 patients were included from 18 studies (13 prospective and 5 retrospective) comparing (D-EPD) and (P-EPD) in the setting of CAS. The mean patient age was 69 years and 64% of patients were male. No evidence of publication bias was detected. There was no significant difference between the two modalities in terms of the risk of stroke (risk difference [RD] 0.0, 95% confidence interval [CI] -0.01 to 0.01) or mortality (RD 0.0, 95% CI -0.01 to 0.01) nor was there any difference in the incidence of new cerebral lesions on DW-MRI or contralateral DW-MRI lesions.

CONCLUSIONS

In patients undergoing CAS, both D-EPD and P-EPD provide similar levels of protection from peri-procedural stroke and 30 days mortality. © 2016 Wiley Periodicals, Inc.

Regional variation in patient selection and treatment for carotid artery disease in the Vascular Quality Initiative

OBJECTIVE

Previous studies involving large administrative data sets have revealed regional variation in the demographics of patients selected for carotid endarterectomy (CEA) and carotid artery stenting (CAS) but lacked clinical granularity. This study aimed to evaluate regional variation in patient selection and operative technique for carotid artery revascularization using a detailed clinical registry.

METHODS

All patients who underwent CEA or CAS from 2009 to 2015 were identified in the Vascular Quality Initiative (VQI). Deidentified regional groups were used to evaluate variation in patient selection, operative technique, and perioperative management. χ² analysis was used to identify significant variation across regions.

RESULTS

A total of 57,555 carotid artery revascularization procedures were identified. Of these, 49,179 patients underwent CEA (asymptomatic: median, 56%; range, 46%-69%; P < .01) and 8376 patients underwent CAS (asymptomatic: median, 36%; range, 29%-51%; P < .01). There was significant regional variation in the proportion of asymptomatic patients being treated for carotid stenosis <70% in CEA (3%-9%; P < .01) vs CAS (3%-22%; P < .01). There was also significant variation in the rates of intervention for asymptomatic patients older than 80 years (CEA, 12%-27% [P < .01]; CAS, 8%-26% [P < .01]). Preoperative computed tomography angiography or magnetic resonance angiography in the CAS cohort also varied widely (31%-83%; P < .01), as did preoperative medical management with combined aspirin and statin (CEA, 53%-77% [P < .01]; CAS, 62%-80% [P < .01]). In the CEA group, the use of shunt (36%-83%; P < .01), protamine (32%-89%; P < .01), and patch (87%-99%; P < .01) varied widely. Similarly, there was regional variation in frequency of CAS done without a protection device (1%-8%; P < .01).

CONCLUSIONS

Despite clinical benchmarks aimed at guiding management of carotid disease, wide variation in clinical practice exists, including the proportion of asymptomatic patients being treated by CAS and preoperative medical management. Additional intraoperative variables, including the use of a patch and protamine during CEA and use of a protection device during CAS, displayed similar variation in spite of clear guidelines. Quality improvement projects could be directed toward improved adherence to benchmarks in these areas.

The effect of increasing operator experience on procedure-related characteristics in patients undergoing carotid artery stenting

Objectives To evaluate the efficacy and safety of carotid artery stenting for the treatment of severe carotid artery disease in our department and to investigate the effect of increasing operator experience on perioperative and procedure-related characteristics. Methods From January 2007 to February 2015 200 patients underwent 207 endovascular procedures for carotid artery stenosis. Of all, 113 arteries (56.5%) were symptomatic. Significant changes across time were calculated with the use of Change Point analysis using bootstrap and mean squared error estimates. Results The technical success was 98.6% (204/207 cases). Thirty-day neurological events included stroke in four patients (2%) and transient ischemic attack in two (1%). None of the patients died during the first 30 days. The most significant change of radiation duration occurred after the 33rd patient with a decrease from 25.31 min to 12.31 min, while for the total operative time that change occurred between the 31st and 33rd patient where mean operation time decreased from 88.89 min to 49.22 min. The most significant change of contrast media used occurred at the 40th patient with a decrease from 91.58 ml to 62 ml. During a mean follow-up period of 42 ± 20.02 months none of the patients experienced any cerebrovascular event. There was one case of significant recurrent stenosis, which was successfully treated by endovascular means. Conclusions Endovascular treatment of carotid artery stenosis performed in a single center with the use of a cerebral protection device seems to consist a safe therapeutic choice with acceptable results, within the referenced benchmarks proposed in the latest guidelines. Certain perioperative parameters such as the amount of contrast media used, the fluoroscopy and operation time, seem to decline overtime indicating increasing operator's experience. A number of performed cases above 40 was related to the significant decrease of those parameters and may represent the learning curve of the procedure.

Incidence and risk factors of embolized particles in carotid artery stenting and association with clinical outcome

BACKGROUND

One of the mechanisms for periprocedural neurologic events in carotid artery stenting (CAS) is catheter manipulation within the aorta and supraaortic arteries causing plaque embolization. Therefore, the present analysis sought to determine risk factors for embolic particle dimensions and their relationship with adverse clinical events after CAS.

METHODS

Between 1999 and 2015 embolic protection devices (EPD) of a total of 944 CAS procedures were evaluated regarding the occurrence and size of captured particles.

RESULTS

Particles were found in 819 of 944 (87%) EPDs. Larger particles were detected in procedures using open cell stents (150±282μm vs. 107±177μm; p=0.005) and longer stents (≥40mm) (165±315μm vs. 122±215μm; p=0.026). With increasing learning curve, particle size was continually reduced (168±282μm in the first third of the cohort vs. 127±309μm in the second third vs. 108±114μm in the last third; p=0.009). Longer stents and use of Acculink stent were found to be independent predictors for particle diameter. In patients who died or sustained a stroke during long-term follow-up (median 5.5years [IQR 2.6-7.9]) significantly larger particles were captured during CAS compared to those patients with an uneventful follow-up (160±330μm vs. 121±195μm; p=0.047).

CONCLUSIONS

In the vast majority of CAS procedures particles could be retrieved from the EPDs used. Procedural characteristics such as stent type and stent length were associated with larger particles.

Carotid artery stenting with a new-generation double-mesh stent in three high-volume Italian centres: clinical results of a multidisciplinary approach

AIMS

Carotid artery stenting (CAS) is still associated with higher periprocedural cerebrovascular events (CEs) compared to vascular surgery. The Roadsaver carotid artery stent is a double layer micromesh stent which reduces plaque prolapse and embolisation by improving plaque coverage. Its clinical impact on neurological outcome was unknown. The aim of this study was therefore to report the clinical results of a large real-world population from three different centres receiving a Roadsaver stent to treat carotid artery disease.

METHODS AND RESULTS

One hundred and fifty (150) patients (age 74±8 yrs, 75% male, symptomatic 29%) treated with CAS using the Roadsaver carotid stent in three high-volume Italian centres were included in the study. Intraprocedural optical coherence tomography (OCT) evaluation was performed in 26 patients, with an off-line analysis by a dedicated core laboratory. All patients underwent duplex ultrasound and neurological evaluation at 24 hours and at 30 days. CAS was technically successful in all cases (stent diameter: 8.6±0.8 mm, stent length: 25.0±4.5 mm). No in-hospital or 30-day CEs were observed. OCT evaluation detected a low rate of plaque prolapse (two patients, 7.7%). Duplex ultrasound showed stent and external carotid artery patency in all cases both before discharge and at 30-day follow-up.

CONCLUSIONS

The Roadsaver stent is a safe and promising technology for CAS, with a low percentage of plaque prolapse and good short-term clinical outcome. Larger studies with longer follow-up are necessary to confirm this favourable clinical outcome.

Carotid stenting versus endarterectomy for the treatment of carotid artery stenosis: Contemporary results from a large single center study

OBJECTIVE

To compare the complication rates associated with carotid endarterectomy (CEA) versus carotid artery stenting (CAS).

BACKGROUND

Carotid stenosis is a well-known cause of stroke and increased mortality. The safety of carotid revascularization may be related to symptom status, medical comorbidities, use of embolic protection devices, as well as operator experience and these factors may vary across patient populations within a single operating center.

METHODS

We retrospectively analyzed patients with carotid artery stenosis admitted to our hospital for carotid revascularization between January 1, 2007 and December 1, 2013. The primary end point was a composite endpoint of periprocedural death, stroke, and myocardial infarction (MI).

RESULTS

Of the 718 patients admitted for carotid revascularization 525 (73.1%) underwent CEA and 193 (26.9%) underwent CAS. Both groups demonstrated similar rates of the composite endpoint, MI, and death; the stenting group demonstrated a higher rate of stroke (4.2% vs. 1.3%; P = 0.020). Adjusting for baseline medical comorbidities and symptom status mitigated this difference (P = 0.091 and 0.113, respectively). When stratified by department performing CAS, there was a significant difference in the occurrence of stroke (P = 0.033), which likewise disappeared in the multivariate regression analysis.

CONCLUSION

The risk of the composite endpoint did not differ significantly between those undergoing CAS versus CEA. The stenting group demonstrated a higher rate of periprocedural stroke, which was also apparent when patients were stratified by stenting department. These differences were likely driven by variation in baseline medical comorbidities and symptom status. © 2016 Wiley Periodicals, Inc.

Proximal versus distal embolic protection for carotid artery stenting: a national cardiovascular data registry analysis

OBJECTIVES

The aim of this study was to compare the stroke/death rates between proximal embolic protection devices (P-EPDs) and distal filter embolic protection devices (F-EPDs) in elective carotid artery stenting (CAS).

BACKGROUND

P-EPDs have theoretical advantages that may make them superior to F-EPDs for stroke prevention during CAS.

METHODS

We examined 10,246 consecutive elective CAS procedures performed with embolic protection in the NCDR CARE registry between January 2009 and March 2013. We analyzed crude and propensity-matched rates of in-hospital combined death/stroke in patients treated with P-EPDs versus F-EPDs. Secondary analyses included 30-day adverse event rates and stroke rates by the involved cerebrovascular territory.

RESULTS

P-EPDs were used in 590 of 10,246 cases (5.8%). Patients treated with P-EPDs had higher rates of symptomatic lesion status (46.8% vs. 39.7%, p<0.001), atrial fibrillation/flutter (16.1% vs. 13.0%, p=0.03), and history of a neurological event (51.2% vs. 46.6%, p=0.03). In unadjusted and propensity-matched analyses, differences in in-hospital stroke/death between P-EPD and F-EPD cohorts were nonsignificant (1.5% vs. 2.4%, p=0.16 and 1.6% vs. 2.0%, p=0.56, respectively). For patients with available data (n=7,693, 75.1%), 30-day adverse events rates were similar for P-EPDs and F-EPDs before (2.5% vs. 4.2%, p=0.07) and after (2.7% vs. 4.0%, p=0.22) propensity matching.

CONCLUSIONS

Use of a P-EPD during CAS was associated with low rates of in-hospital stroke/death similar to those with an F-EPD in the first comparative effectiveness study of the devices. An adequately powered randomized trial comparing clinical outcomes between these devices is unlikely to be feasible.