Neuroprotection During Carotid Angioplasty and Stenting: Comparison of No Protection, Occlusion, or Filters

Abstract

A variety of distal emboli protection systems are in development for carotid angioplasty and stenting, each of which may be associated with its own unique capability to capture emboli. This retrospective study was undertaken to compare the incidence and type of peri-procedural (1-month) neurological events using a variety of microembolization protection strategies. This is a retrospective review of 127 consecutive procedures performed over a period of 4 years solely by vascular surgeons. This analysis was restricted to outcomes associated with the treatment of carotid bifurcation lesions. Overall, angioplasty and stenting was performed without distal protection in 32 patients. Of the remaining 95 patients, protection devices included a distal occlusion balloon (n = 18), a Filterwire (n = 54), an Accunet filter (n = 22), and a Sci-pro device (n = l). Patients were considered at high risk for open surgery due to prior endarterectomy (n = 43), radiation (n = 9), high lesion (n = 3), or cardiopulmonary comorbididity (n = 37). A majority of patients (n = 92; 73%) had an asymptomatic >80% stenosis. All procedures were done without sedation and with continuous neurological monitoring. Periprocedural neurological events were classified as a transient ischemic attack (TIA), minor or major stroke, or seizure. In the absence of distal protection, TIAs lasting fewer than 10 min were observed in four patients with an additional patient suffering a minor stroke. Seizure-like activity was observed in two patients during balloon inflation. Among those in whom a filter-based embolization protection device was utilized, TIAs were noted in three patients and none developed either a minor or major stroke. Periprocedural events were not observed with the use of distal balloon protection, although one patient had a TIA 3 weeks after intervention. All neurological events occurred during post-stent dilatation and only among patients with prior neurological symptoms and de novo lesion. Intra-operative neurological events were significantly more common in the absence of protected stenting (n = 7, 21.8%), when compared to filter protection (n = 3, 4%) or complete distal occlusion (n = 0, 0%) (p = 0.0025). However, the majority of these events were transient without permanent neurological deficit. The overall incidence of major stroke/mortality rate was 0.8%. Carotid angioplasty and stenting is a safe and effective procedure when undertaken with adequate distal protection. Adverse neurological events can be minimized by avoiding aggressive post-stent dilatation.