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Predictors of antegrade flow at internal carotid artery during carotid artery stenting with proximal protection

  • Original Article - Vascular
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Abstract

Background

Carotid artery stenting (CAS) with proximal occlusion effectively prevent distal cerebral embolism by flow arrest at internal carotid artery (ICA); however, the method can expose antegrade flow at ICA due to incomplete flow arrest. The aim of this study was to identify predictors of antegrade flow during CAS with proximal protection.

Methods

We retrospectively analyzed clinical and angiographic data among 143 lesions treated with CAS with proximal protection by occluding the common carotid artery (CCA) and external carotid artery (ECA). Flow arrest or antegrade flow at ICA was confirmed by contrast injection during proximal protection.

Results

Antegrade flow at ICA was observed in 12 lesions (8.4%). Compared with lesions in which flow arrest of ICA was achieved, the diameter of the superior thyroid artery (STA) was significantly larger (2.4 ± 0.34 vs. 1.4 ± 0.68 mm, p < 0.001), and the rate of ECA branches other than the STA located 0–10 mm above the bifurcation was significantly higher (50 vs. 8.4%, p < 0.001). Results of multivariate analysis revealed that a diameter of the STA ≥ 2.3 mm (OR 44, 95% CI 8.1–237; p < 0.001) and ECA branches other than the STA located 0–10 mm above the bifurcation (OR 6.0, 95% CI 1.1–32; p = 0.036) were independent predictors of antegrade flow.

Conclusions

Distal filter protection should be combined with proximal protection for the lesions with antegrade flow to prevent distal migration of the carotid debris.

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Abbreviations

CAS:

Carotid artery stenting

ICA:

Internal carotid artery

CCA:

Common carotid artery

ECA:

External carotid artery

STA:

Superior thyroid artery

EPD:

Embolic protection device

MRI:

Magnetic resonance imaging

T1W:

T1 weighted

rSI:

Relative signal intensity

LA:

Lingual artery

FA:

Facial artery

OA:

Occipital artery

ROC:

Receiver-operating characteristic

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Authors and Affiliations

  1. Department of Neurosurgery, Fukuoka Wajiro Hispital, 2-2-75, Wajirogaoka, Higashi-Ku, Fukuoka-city, Fukuoka, 811-0213, Japan

    Kei Harada, Kosuke Kakumoto, Shogo Oshikata & Kozo Fukuyama

Authors
  1. Kei Harada
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  2. Kosuke Kakumoto
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  3. Shogo Oshikata
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  4. Kozo Fukuyama
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Corresponding author

Correspondence to Kei Harada.

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Ethical approval

For this type of study, formal consent is not required.

Informed consent

Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.

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Comments

Carotid artery stenting (CAS) with proximal occlusion is theoretically the most effective procedure to prevent distal cerebral embolism by flow arrest at internal carotid artery (ICA). However, existence of antegrade flow at ICA during proximal protection may cause embolic stroke. The authors clearly demonstrated occurrence rate (8.4%) and predictors of the antegrade flow in this interesting report. Additionally, their strategy using distal filter device in addition to proximal balloon protection can prevent distal cerebral embolism even in presence of the antegrade flow. This report is interesting and will give an important information for the readers.

Kenji Sugiu

Okayama, Japan

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Harada, K., Kakumoto, K., Oshikata, S. et al. Predictors of antegrade flow at internal carotid artery during carotid artery stenting with proximal protection. Acta Neurochir 160, 1121–1127 (2018). https://doi.org/10.1007/s00701-018-3487-y

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  • DOI: https://doi.org/10.1007/s00701-018-3487-y

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