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Carotid Artery Interventions: Thromboembolic Protection

  • Salvatore Cassese
  • Sebastian Kufner
  • Massimiliano Fusaro
Chapter

Abstract

The percutaneous treatment of carotid artery disease is associated with a not negligible risk of cerebral embolization even in cases performed in high-volume centers by trained operators. The use of cerebral protection is advocated to reduce the burden of thromboembolism associated with carotid artery interventions. Here we describe the main technical features and the available clinical data of embolic protection devices and new stents with anti-embolic designs for carotid artery interventions.

References

  1. 1.
    Writing Group Members, Mozaffarian D, Benjamin EJ, et al. Executive summary: heart disease and stroke statistics–2016 update: a report from the American Heart Association. Circulation. 2016;133:447–54.CrossRefGoogle Scholar
  2. 2.
    European Stroke Organization, Tendera M, Aboyans V, et al. ESC guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the task force on the diagnosis and treatment of peripheral artery diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:2851–906.CrossRefGoogle Scholar
  3. 3.
    Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011;124:489–532.CrossRefPubMedGoogle Scholar
  4. 4.
    Schmidt A, Diederich KW, Scheinert S, et al. Effect of two different neuroprotection systems on microembolization during carotid artery stenting. J Am Coll Cardiol. 2004;44:1966–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Montorsi P, Caputi L, Galli S, et al. Microembolization during carotid artery stenting in patients with high-risk, lipid-rich plaque. A randomized trial of proximal versus distal cerebral protection. J Am Coll Cardiol. 2011;58:1656–63.CrossRefPubMedGoogle Scholar
  6. 6.
    Theron JG, Payelle GG, Coskun O, Huet HF, Guimaraens L. Carotid artery stenosis: treatment with protected balloon angioplasty and stent placement. Radiology. 1996;201:627–36.CrossRefPubMedGoogle Scholar
  7. 7.
    Vos JA. Evidence overview: benefit of cerebral protection devices during carotid artery stenting. J Cardiovasc Surg. 2016;58(2):170–7.Google Scholar
  8. 8.
    Cosottini M, Michelassi MC, Puglioli M, et al. Silent cerebral ischemia detected with diffusion-weighted imaging in patients treated with protected and unprotected carotid artery stenting. Stroke. 2005;36:2389–93.CrossRefPubMedGoogle Scholar
  9. 9.
    Giri J, Parikh SA, Kennedy KF, et al. Proximal versus distal embolic protection for carotid artery stenting: a national cardiovascular data registry analysis. JACC Cardiovasc Interv. 2015;8:609–15.CrossRefPubMedGoogle Scholar
  10. 10.
    Mousa AY, Campbell JE, Aburahma AF, Bates MC. Current update of cerebral embolic protection devices. J Vasc Surg. 2012;56:1429–37.CrossRefPubMedGoogle Scholar
  11. 11.
    Bosiers M, Deloose K, Torsello G, et al. The CLEAR-ROAD study: evaluation of a new dual layer micromesh stent system for the carotid artery. EuroIntervention J EuroPCR Collaboration Working Group Interv Cardiol Eur Soc Cardiol. 2016;12:e671–6.CrossRefGoogle Scholar
  12. 12.
    Musialek P, Mazurek A, Trystula M, et al. Novel PARADIGM in carotid revascularisation: prospective evaluation of all-comer peRcutaneous cArotiD revascularisation in symptomatic and increased-risk asymptomatic carotid artery stenosis using CGuard MicroNet-covered embolic prevention stent system. EuroIntervention J EuroPCR Collaboration Working Group Interv Cardiol Eur Soc Cardiol. 2016;12:e658–70.CrossRefGoogle Scholar
  13. 13.
    Stabile E, Salemme L, Sorropago G, et al. Proximal endovascular occlusion for carotid artery stenting: results from a prospective registry of 1,300 patients. J Am Coll Cardiol. 2010;55:1661–7.CrossRefPubMedGoogle Scholar
  14. 14.
    Bersin RM, Stabile E, Ansel GM, et al. A meta-analysis of proximal occlusion device outcomes in carotid artery stenting. Catheter Cardiovasc Interv Off J Soc Card Angiography Interv. 2012;80:1072–8.CrossRefGoogle Scholar
  15. 15.
    Stabile E, Rubino P, Montorsi P. Clamping intolerance during proximal protected carotid artery stenting. Catheter Cardiovasc Interv Off J Soc Card Angiography Interv. 2013;82:60–1.CrossRefGoogle Scholar
  16. 16.
    Sfyroeras GS, Moulakakis KG, Markatis F, et al. Results of carotid artery stenting with transcervical access. J Vasc Surg. 2013;58:1402–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Criado E, Doblas M, Fontcuberta J, et al. Transcervical carotid stenting with internal carotid artery flow reversal: feasibility and preliminary results. J Vasc Surg. 2004;40:476–83.CrossRefPubMedGoogle Scholar
  18. 18.
    Kwolek CJ, Jaff MR, Leal JI, et al. Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal. J Vasc Surg. 2015;62:1227–34.CrossRefPubMedGoogle Scholar
  19. 19.
    Iyer V, de Donato G, Deloose K, et al. The type of embolic protection does not influence the outcome in carotid artery stenting. J Vasc Surg. 2007;46:251–6.CrossRefPubMedGoogle Scholar
  20. 20.
    Bates MC, Campbell JE. Pitfalls of embolic protection. Tech Vasc Interv Radiol. 2011;14:101–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Gray WA, Hopkins LN, Yadav S, et al. Protected carotid stenting in high-surgical-risk patients: the ARCHeR results. J Vasc Surg. 2006;44:258–68.CrossRefPubMedGoogle Scholar
  22. 22.
    Matsumura JS, Gray W, Chaturvedi S, Yamanouchi D, Peng L, Verta P. Results of carotid artery stenting with distal embolic protection with improved systems: protected carotid artery stenting in patients at high risk for carotid endarterectomy (PROTECT) trial. J Vasc Surg. 2012;55:968–976.e5.CrossRefPubMedGoogle Scholar
  23. 23.
    Iyer SS, White CJ, Hopkins LN, et al. Carotid artery revascularization in high-surgical-risk patients using the carotid WALLSTENT and FilterWire EX/EZ: 1-year outcomes in the BEACH Pivotal Group. J Am Coll Cardiol. 2008;51:427–34.CrossRefPubMedGoogle Scholar
  24. 24.
    Hopkins LN, Myla S, Grube E, et al. Carotid artery revascularization in high surgical risk patients with the NexStent and the Filterwire EX/EZ: 1-year results in the CABERNET trial. Catheter Cardiovasc Interven Off J Soc Card Angiography Interv. 2008;71:950–60.CrossRefGoogle Scholar
  25. 25.
    Safian RD, Jaff MR, Bresnahan JF, et al. Protected carotid stenting in high-risk patients: results of the SpideRX arm of the carotid revascularization with ev3 arterial technology evolution trial. J Interv Cardiol. 2010;23:491–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351:1493–501.CrossRefPubMedGoogle Scholar
  27. 27.
    Hornung M, Franke J, Bertog SC, Gafoor S, Grunwald I, Sievert H. Initial experience using the gore embolic filter in carotid interventions. J Invasive Cardiol. 2016;28:334–9.PubMedGoogle Scholar
  28. 28.
    Myla S, Bacharach JM, Ansel GM, Dippel EJ, McCormick DJ, Popma JJ. Carotid artery stenting in high surgical risk patients using the FiberNet embolic protection system: the EPIC trial results. Catheter Cardiovasc Interv Off J Soc Card Angiography Interv. 2010;75:817–22.Google Scholar
  29. 29.
    Fanelli F, Bezzi M, Boatta E, Passariello R. Carotid intervention 3: the evidence for cerebral protection. Semin Interv Radiol. 2007;24:234–43.CrossRefGoogle Scholar
  30. 30.
    Casserly IP, Abou-Chebl A, Fathi RB, et al. Slow-flow phenomenon during carotid artery intervention with embolic protection devices: predictors and clinical outcome. J Am Coll Cardiol. 2005;46:1466–72.CrossRefPubMedGoogle Scholar
  31. 31.
    Roffi M, Greutmann M, Schwarz U, Luscher TF, Eberli FR, Amann-Vesti B. Flow impairment during protected carotid artery stenting: impact of filter device design. J Endovasc Ther Off J Int Soc Endovasc Specialists. 2008;15:103–9.CrossRefGoogle Scholar
  32. 32.
    Cassese S, Ndrepepa G, King LA, et al. Proximal occlusion versus distal filter for cerebral protection during carotid stenting: updated meta-analysis of randomised and observational MRI studies. EuroIntervention J EuroPCR collaboration Working Group Interv Card Eur Soc Cardiol. 2015;11:238–46.CrossRefGoogle Scholar
  33. 33.
    Morr S, Lin N, Siddiqui AH. Carotid artery stenting: current and emerging options. Med Devices. 2014;7:343–55.Google Scholar
  34. 34.
    Gress DR. The problem with asymptomatic cerebral embolic complications in vascular procedures: what if they are not asymptomatic? J Am Coll Cardiol. 2012;60:1614–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Giri J, Kennedy KF, Weinberg I, et al. Comparative effectiveness of commonly used devices for carotid artery stenting: an NCDR analysis (National Cardiovascular Data Registry). JACC Cardiovasc Interv. 2014;7:171–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Fiebach JB, Schellinger PD, Jansen O, et al. CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke. Stroke. 2002;33:2206–10.CrossRefPubMedGoogle Scholar
  37. 37.
    Bijuklic K, Wandler A, Tubler T, Schofer J. Impact of asymptomatic cerebral lesions in diffusion-weighted magnetic resonance imaging after carotid artery stenting. JACC Cardiovasc Interv. 2013;6:394–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Maggio P, Altamura C, Landi D, et al. Diffusion-weighted lesions after carotid artery stenting are associated with cognitive impairment. J Neurol Sci. 2013;328:58–63.CrossRefPubMedGoogle Scholar
  39. 39.
    Zhou W, Hitchner E, Gillis K, et al. Prospective neurocognitive evaluation of patients undergoing carotid interventions. J Vasc Surg. 2012;56:1571–8.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Hogan AM, Shipolini A, Brown MM, Hurley R, Cormack F. Fixing hearts and protecting minds: a review of the multiple, interacting factors influencing cognitive function after coronary artery bypass graft surgery. Circulation. 2013;128:162–71.CrossRefPubMedGoogle Scholar
  41. 41.
    Bijuklic K, Wandler A, Hazizi F, Schofer J. The PROFI study (prevention of cerebral embolization by proximal balloon occlusion compared to filter protection during carotid artery stenting): a prospective randomized trial. J Am Coll Cardiol. 2012;59:1383–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Cano MN, Kambara AM, de Cano SJ, et al. Randomized comparison of distal and proximal cerebral protection during carotid artery stenting. JACC Cardiovasc Interv. 2013;6:1203–9.CrossRefPubMedGoogle Scholar
  43. 43.
    El-Koussy M, Schroth G, Do DD, et al. Periprocedural embolic events related to carotid artery stenting detected by diffusion-weighted MRI: comparison between proximal and distal embolus protection devices. J Endovasc Ther Off J Int Soc Endovasc Specialists. 2007;14:293–303.CrossRefGoogle Scholar
  44. 44.
    Flach ZH, Ouhlous M, Hendriks JM, et al. Diffusion-weighted imaging to compare different cerebral protection devices in carotid artery stenting. EuroIntervention J EuroPCR Collaboration Working Group Interv Card Eur Soc Cardiol. 2007;3:243–8.CrossRefGoogle Scholar
  45. 45.
    Castro-Afonso LH, Abud LG, Rolo JG, et al. Flow reversal versus filter protection: a pilot carotid artery stenting randomized trial. Circ Cardiovasc Interv. 2013;6:552–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Stabile E, Sannino A, Schiattarella GG, et al. Cerebral embolic lesions detected with diffusion-weighted magnetic resonance imaging following carotid artery stenting: a meta-analysis of 8 studies comparing filter cerebral protection and proximal balloon occlusion. JACC Cardiovasc Interv. 2014;7:1177–83.CrossRefPubMedGoogle Scholar
  47. 47.
    Omran J, Mahmud E, White CJ, et al. Proximal balloon occlusion versus distal filter protection in carotid artery stenting: a meta-analysis and review of the literature. Catheter Cardiovasc Interv Off J Soc Card Angiography Interv. 2016;89(5):923–31.CrossRefGoogle Scholar
  48. 48.
    Vuruskan E, Saracoglu E, Ergun U, Poyraz F, Veysel DI. Carotid artery stenting with double cerebral embolic protection in asymptomatic patients – a diffusion-weighted MRI controlled study. VASA Zeitschrift fur Gefasskrankheiten. 2017;46:29–35.CrossRefPubMedGoogle Scholar
  49. 49.
    Varbella F, Gagnor A, Rolfo C, et al. Feasibility of carotid artery stenting with double cerebral embolic protection in high-risk patients. Catheter Cardiovasc Interv Off J Soc Card Angiography Interv. 2016;87:432–7.CrossRefGoogle Scholar
  50. 50.
    Safian RD. Double cerebral embolic protection: is more less? Catheter Cardiovasc Interv Off J Soc Card Angiography Interv. 2016;87:438–9.CrossRefGoogle Scholar
  51. 51.
    Stabile E, Giugliano G, Cremonesi A, et al. Impact on outcome of different types of carotid stent: results from the European registry of carotid artery stenting. EuroIntervention J EuroPCR Collaboration Working Group Interv Cardiol Eur Soc Cardiol. 2016;12:e265–70.CrossRefGoogle Scholar
  52. 52.
    de Donato G, Setacci F, Sirignano P, Galzerano G, Cappelli A, Setacci C. Optical coherence tomography after carotid stenting: rate of stent malapposition, plaque prolapse and fibrous cap rupture according to stent design. Eur J Vasc Endovasc Surg Off J Eur Soc Vasc Surg. 2013;45:579–87.CrossRefGoogle Scholar
  53. 53.
    Schofer J, Musialek P, Bijuklic K, et al. A prospective, multicenter study of a novel mesh-covered carotid stent: the CGuard CARENET trial (carotid embolic protection using MicroNet). JACC Cardiovasc Interv. 2015;8:1229–34.CrossRefPubMedGoogle Scholar
  54. 54.
    Wissgott C, Schmidt W, Brandt-Wunderlich C, Behrens P, Andresen R. Clinical results and mechanical properties of the carotid CGUARD double-layered embolic prevention stent. J Endovasc Ther Off J Int Soc Endovasc Specialists. 2017;24:130–7.CrossRefGoogle Scholar
  55. 55.
    Nerla R, Castriota F, Micari A, et al. Carotid artery stenting with a new-generation double-mesh stent in three high-volume Italian centres: clinical results of a multidisciplinary approach. EuroIntervention J EuroPCR Collaboration Working Group Interv Cardiol the Eur Soc Cardiol. 2016;12:e677–83.CrossRefGoogle Scholar
  56. 56.
    Schonholz C, Yamada R, Montgomery W, Brothers T, Guimaraes M. First-in-man implantation of a new hybrid carotid stent to prevent periprocedural neurological events during carotid artery stenting. J Endovasc Ther Off J Int Soc Endovasc Specialists. 2014;21:601–4.CrossRefGoogle Scholar
  57. 57.
    Bosiers M, Deloose K, Verbist J, Peeters P. What practical factors guide the choice of stent and protection device during carotid angioplasty? Eur J Vasc Endovasc Surg Off J Eur Soc Vasc Surg. 2008;35:637–43.CrossRefGoogle Scholar
  58. 58.
    Staubach S, Hein-Rothweiler R, Hochadel M, et al. Predictors of minor versus major stroke during carotid artery stenting: results from the carotid artery stenting (CAS) registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK). Clin Res Cardiol Off J Ger Card Soc. 2014;103:345–51.CrossRefGoogle Scholar
  59. 59.
    Stabile E, Esposito G. Operator’s experience is the most efficient embolic protection device for carotid artery stenting. Circ Cardiovasc Interv. 2013;6:496–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Salvatore Cassese
    • 1
  • Sebastian Kufner
    • 1
  • Massimiliano Fusaro
    • 1
  1. 1.Deutsches Herzzentrum München, Technische Universität MünchenMunichGermany

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