Skip to main content

Advertisement

SpringerLink
Log in

Risk factors for periprocedural complications in carotid artery stenting without filter protection

A serial diffusion–weighted MRI study

  • ORIGINAL COMMUNICATION
  • Published:
Journal of Neurology Aims and scope Submit manuscript

Abstract

Introduction

In highgrade stenosis, carotid artery stenting (CAS) may be chosen as an alternative to carotid surgery. Ischemic periprocedural complications may be documented best with diffusion–weighted MRI (DWMRI). In this prospective study serial DW–MRI and color–coded duplex sonography (CCDS) were used to identify carotid stenosis, which is associated with an increased risk of ischemic events due to CAS.

Methods

High resolution DW–MRI were performed in 74 out of 77 patients before and after CAS. All MRI scans were analyzed in a blinded manner. With CCDS each carotid stenosis was evaluated according to the grade, length, echo properties and plaque surface.

Results

In 42 out of 74 patients (56.8 %) a total of 188 new procedure– related DWI–lesions could be detected, while in 32 patients MRI–controls remained normal. Of the lesions 79.25 % had a size < 1 cm. In one major and two minor strokes due to CAS (total complication rate 3.9 %) corresponding territorial infarcts could be demonstrated. A highly significant correlation was found between the length of the stenosis and the incidence of new DWI–lesions (p = 0.0141). In contrast, neither the grade of ICA stenosis nor the sonographic plaque morphology or plaque surface correlated with the number of DWI–lesion in postinterventional scans.

Conclusions

The length—and not the degree—of an ICA stenosis seems to be the most decisive sonographic factor for estimating the periprocedural risk of embolism. DWI–lesions are much more frequent than clinical complications and may represent an important surrogate marker for improving the techniques of carotid artery stenting, especially comparing the benefit of different mechanical protection devices.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Phatouros CC, Higashida RT, Malek AM, Meyers PM, Lempert TE, Dowd CF, et al. (2000) Carotid artery stent placement for atherosclerotic disease: rationale, technique and current status. Radiology 217:26–41

    CAS  PubMed  Google Scholar 

  2. Roubin GS, New G, Iyer SS, Vitek JJ, Al Mubarak N, Liu MW, et al. (2001) Immediate and Late Clinical Outcomes of Carotid Artery Stenting in Patients With Symptomatic and Asymptomatic Carotid Artery Stenosis: A 5–Year Prospective Analysis. Circulation 103(4):532–537

    CAS  PubMed  Google Scholar 

  3. Wholey MH, Wholey M, Mathias K, Roubin GS, Diethrich EB, Henry M, et al. (2000) Global experience in cervical carotid artery stent placement. Catheter Cardiovasc Interv 50(2):160–167

    CAS  PubMed  Google Scholar 

  4. Mathur A, Roubin GS, Iyer SS, Piamsonboon C, Liu MW, Gomez CR, et al. (1998) Predictors of Stroke Complicating Carotid Artery Stenting. Circulation 97:1239–1245

    CAS  PubMed  Google Scholar 

  5. Markus HS, Clifton A, Buckenham T, Brown MM (1994) Carotid angioplasty. Detection of embolic signals during and after the procedure. Stroke 25:2403–2406

    CAS  PubMed  Google Scholar 

  6. Crawley F, Stygall J, Lunn S, Harrison M, Brown MM, Newman S (2000) Comparison of microembolism detected by transcranial Doppler and neuropsychological sequelae of carotid surgery and percutaneous transluminal angioplasty. Stroke 31:1329–1334

    CAS  PubMed  Google Scholar 

  7. Orlandi G, Fanucchi S, Fioretti C, Acerbi G, Puglioli M, Padolecchia R, et al. (2001) Characteristics of cerebral microembolism during carotid stenting and angioplasty alone. Arch Neurol 58:1410–1413

    Article  CAS  PubMed  Google Scholar 

  8. Bendszus M, Koltzenburg M, Burger R, Warmuth–Metz M, Hofmann E, Solymosi L (1999) Silent embolism in diagnostic cerebral angiography and neurointerventional procedures: a prospective study. Lancet 354(9190):1594–1597

    Article  CAS  PubMed  Google Scholar 

  9. Jaeger HJ, Mathias KD, Drescher R, Hauth E, Bockisch G, Demirel E, et al. (2001) Diffusion–weighted MR imaging after angioplasty or angioplasty plus stenting of arteries supplying the brain. AJNR Am J Neuroradiol 22:1251–1259

    CAS  PubMed  Google Scholar 

  10. Lövblad KO, Plüschke W, Remonda L, Gruber–Wiest D, Do DD, Barth A, et al. (2000) Diffusion–weighted MRI for monitoring neurovascular interventions. Neuroradiology 42:134–138

    PubMed  Google Scholar 

  11. Tomczak R, Wunderlich A, Liewald F, Stuber G, Gorich J (2001) Diffusionweighted MRI: detection of cerebral ischemia before and after carotid thromboendarterectomy. J Comput Assist Tomogr 25:247–250

    Article  CAS  PubMed  Google Scholar 

  12. Forbes KP, Shill HA, Britt PM, Zabramski JM, Spetzler RF, Heiserman JE (2001) Assessment of silent embolism from carotid endarterectomy by use of diffusion–weighted imaging: work in progress. AJNR Am J Neuroradiol 22:650–653

    CAS  PubMed  Google Scholar 

  13. Feiwell RJ, Besmertis L, Sarkar R, Saloner DA, Rapp JH (2001) Detection of clinically silent infarcts after carotid endarterectomy by use of diffusionweighted imaging. AJNR Am J Neuroradiol 22:646–649

    CAS  PubMed  Google Scholar 

  14. Muller M, Reiche W, Langenscheidt P, Hassfeld J, Hagen T (2000) Ischemia after carotid endarterectomy: comparison between transcranial Doppler sonography and diffusion–weighted MR imaging. AJNR Am J Neuroradiol 21:47–54

    CAS  PubMed  Google Scholar 

  15. Carpenter JP, Lexa FJ, Davis JT (1996) Determination of Duplex Doppler Ultrasound Criteria Appropriate to the North American Symptomatic Carotid Endarterectomy Trial. Stroke 27:695–699

    CAS  PubMed  Google Scholar 

  16. Huston J, Nichols DA, Luetmer PH, Rydberg CH, Lewis BD, Meyer FB, et al. (1998) MR angiographic and sonographic indications for endarterectomy. AJNR Am J Neuroradiol 19:309–315

    CAS  PubMed  Google Scholar 

  17. Alexandrov AV, Brodie DS, McLean A, Hamilton P, Murphy J, Burns PN (1997) Correlation of Peak Systolic Velocity and Angiographic Measurement of Carotid Stenosis Revisited. Stroke 28(2):339–342

    CAS  PubMed  Google Scholar 

  18. Goertler M, Widder B, Schuetz U (1996) Quantifying medium– and high–grade carotid artery stenosis by ultrasound. J E M U 17:235–239

    Google Scholar 

  19. Widder B (1999) Doppler– und Duplexsonographie der hirnversorgenden Arterien. 5 ed. Berlin, Heidelberg, New York: Springer

  20. Rubba P, Mercuri M, Faccenda F, Iannuzzi A, Irace C, Strisciuglio P, et al. (1994) Premature carotid atherosclerosis: does it occur in both familial hypercholesterolemia and homocystinuria? Ultrasound assessment of arterial intima–media thickness and blood flow velocity. Stroke 25:943–950

    CAS  PubMed  Google Scholar 

  21. Friese S, Krapf H, Fetter M, Klose U, Skalej M, Küker W (2001) Ultrasonography and contrast–enhanced MRA in ICA–stenosis: is conventional angiography obsolete? J Neurol 248:506–513

    Article  CAS  PubMed  Google Scholar 

  22. Küker W, Weise J, Krapf H, Schmidt F, Friese S, Bähr M (2002) MRI characteristics of acute and subacute brainstem and thalamic infractions: value of T2– and diffusion–weighted sequences. J Neurol 249:33–42

    PubMed  Google Scholar 

  23. Hobson RW, Lal BK, Chakhtoura E, Goldstein J, Haser PB, Kubicka R, et al. (2003) Carotid artery stenting: analysis of data for 105 patients at high risk. J Vasc Surg 37:1234–1239

    PubMed  Google Scholar 

  24. Hahnel S, Bender J, Jansen O, Hartmann M, Knauth M, Busing K, et al. (2001) [Clinically silent cerebral embolisms after cerebral catheter angiography]. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 173:300–305

    CAS  PubMed  Google Scholar 

  25. van Heesewijk HP, Vos JA, Louwerse ES, Van Den Berg JC, Overtoom TT, Ernst SM, et al. (2002) New brain lesions at MR imaging after carotid angioplasty and stent placement. Radiology 224:361–365

    PubMed  Google Scholar 

  26. Alexandrov AV (2003) Ultrasound and angiography in the selection of patients for carotid endarterectomy. Curr Cardiol Rep 5:141–147

    PubMed  Google Scholar 

  27. Kastrup A, Gröschel K, Krapf H, Brehm B, Dichgans J, Schultz J (2003) Early outcome of carotid angioplasty and stenting with and without cerebral protection devices. Stroke 34:813–819

    Article  PubMed  Google Scholar 

  28. Barr JD, Connors JJ, Sacks D, Wojak JC, Becker GJ, Cardella JF, et al. (2003) Quality improvement guidelines for the performance of cervical carotid angioplasty and stent placement. AJNR Am J Neuroradiol 24:2020–2034

    PubMed  Google Scholar 

  29. Mathiesen EB, Bonaa KH, Joakimsen O (2001) Echolucent plaques are associated with high risk of ischemic cerebrovascular events in carotid stenosis: the Tromso study. Circulation 103:2171–2175

    CAS  PubMed  Google Scholar 

  30. Liapis CD, Kakisis JD, Kostakis AG (2001) Carotid stenosis: factors affecting symptomatology. Stroke 32:2782–2786

    CAS  PubMed  Google Scholar 

  31. Orlandi G, Fanucchi S, Fioretti C, Acerbi G, Puglioli M, Padolecchia R, et al. (2001) Characteristics of cerebral microembolism during carotid stenting and angioplasty alone. Arch Neurol 58:1410–1413

    Article  CAS  PubMed  Google Scholar 

  32. Tegos TJ, Sabetai MM, Nicolaides AN, Elatrozy TS, Dhanjil S, Stevens JM (2001) Patterns of brain computed tomography infarction and carotid plaque echogenicity. J Vasc Surg 33:334–339

    CAS  PubMed  Google Scholar 

  33. Wholey MH, Wholey M (2003) Current status in cervical carotid artery stent placement. J Cardiovasc Surg (Torino) 44:331–339

    CAS  Google Scholar 

  34. Castriota F, Cremonesi A, Manetti R, Liso A, Oshola K, Ricci E, et al. (2002) Impact of cerebral protection devices on early outcome of carotid stenting. J Endovasc Ther 9:786–792

    Article  PubMed  Google Scholar 

  35. Jaeger H, Mathias K, Drescher R, Hauth E, Bockisch G, Demirel E, et al. (2001) Clinical results of cerebral protection with a filter device during stent implantation of the carotid artery. Cardiovasc Intervent Radiol 24:249–256

    Article  CAS  PubMed  Google Scholar 

  36. Macdonald S, McKevitt F, Venables GS, Cleveland TJ, Gaines PA (2002) Neurological outcomes after carotid stenting protected with the NeuroShield filter compared to unprotected stenting. J Endovasc Ther 9:777–785

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Dept. of Neuroradiology, University of Tuebingen, Tuebingen, Germany

    H. Krapf MD, Th. Nägele MD, U. Bühring MD, E. Grönewäller MD, M. Skalej MD & W. Küker MD

  2. Dept. of Neurology, University of Tuebingen, Tuebingen, Germany

    A. Kastrup MD

  3. Dept. of Neuroradiology, The Radcliffe Infirmary, Woodstock Road, Oxford OX2 6HE, UK

    W. Küker MD

Authors
  1. H. Krapf MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Th. Nägele MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. A. Kastrup MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. U. Bühring MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. E. Grönewäller MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. M. Skalej MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. W. Küker MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to W. Küker MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Krapf, H., Nägele, T., Kastrup, A. et al. Risk factors for periprocedural complications in carotid artery stenting without filter protection. J Neurol 253, 364–371 (2006). https://doi.org/10.1007/s00415-005-0005-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00415-005-0005-y

Key words

Search

Navigation