J Korean Neurosurg Soc.  2015 Oct;58(4):316-320. 10.3340/jkns.2015.58.4.316.

Clinical Analysis Comparing Efficacy between a Distal Filter Protection Device and Proximal Balloon Occlusion Device during Carotid Artery Stenting

• Lee JH
• Sohn HE
• Chung SY
• Park MS
• Kim SM
• Lee DS

• KMID: 2114366
• DOI: http://doi.org/10.3340/jkns.2015.58.4.316

Abstract

OBJECTIVE
The main concern during transfemoral carotid artery stenting (CAS) is preventing cerebral embolus dislodgement. We compared clinical outcomes and intraprocedural embolization rates of CAS using a distal filter protection device or proximal balloon occlusion device.
METHODS
From January 2011 to March 2015, a series of 58 patients with symptomatic or asymptomatic internal carotid artery stenosis > or =70% were treated with CAS with embolic protection device in single center. All patients underwent post-CAS diffusion-weighted magnetic resonance imaging (DW-MRI) to detect new ischemic lesions. We compared clinical outcomes and postprocedural embolization rates.
RESULTS
CAS was performed in all 61 patients. Distal filter protection success rate was 96.6% (28/29), whose mean age was 70.9 years, and mean stenosis was 81%. Their preprocedural infarction rate was 39% (11/28). Subsequent DW-MRI revealed 96 new ischemic lesions in 71% (20/28) patients. In contrast, the proximal balloon occlusion device success rate was 93.8% (30/32), whose mean age was 68.8 years and mean stenosis was 86%. Preprocedure infarction rate was 47% (14/30). DW-MRI revealed 45 new ischemic lesions in 57% (17/30) patients. Compared with distal filter protection device, proximal balloon occlusion device resulted in fewer ischemic lesions per patient (p=0.028). In each group, type of stent during CAS had no significant effect on number of periprocedural embolisms. Only 2 neurologic events occurred in the successfully treated patients (one from each group).
CONCLUSION
Transfemoral CAS with proximal balloon occlusion device achieves good results. Compared with distal filter protection, proximal balloon occlusion might be more effective in reducing cerebral embolism during CAS.

Keyword

Carotid stenosis; Diffusion magnetic resonance; Embolic protection device; Cerebral infarction

MeSH Terms

Balloon Occlusion*
Carotid Arteries*
Carotid Stenosis
Cerebral Infarction
Constriction, Pathologic
Embolic Protection Devices
Embolism
Humans
Infarction
Intracranial Embolism
Magnetic Resonance Imaging
Stents*

Reference

1. Barnett HJM. NASCET Collaborators. Final results of the North American Symptomatic Carotid Endarterectomy Trial (nascet). Stroke. 1998; 29:286.

2. Biasi GM, Froio A, Diethrich EB, Deleo G, Galimberti S, Mingazzini P, et al. Carotid plaque echolucency increases the risk of stroke in carotid stenting : the Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) study. Circulation. 2004; 110:756–762. PMID: 15277320.

3. 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; 59:1383–1389. PMID: 22284330.

4. Cohen SA, Snead D, Ouriel K, Fayad P, Katzen B, Wholey M, et al. Effectiveness of embolic protection in capturing debris and reducing 30-day stroke rates during carotid stenting. Circulation. 2005; 112:U476.

5. El-Koussy M, Schroth G, Do DD, Gralla J, Nedeltchev K, von Bredow F, 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. 2007; 14:293–303. PMID: 17723007.

6. European Stroke Organisation. Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Clément D, 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; 32:2851–2906. PMID: 21873417.

7. Hauth EA, Jansen C, Drescher R, Schwartz M, Forsting M, Jaeger HJ, et al. MR and clinical follow-up of diffusion-weighted cerebral lesions after carotid artery stenting. AJNR Am J Neuroradiol. 2005; 26:2336–2341. PMID: 16219842.

8. Iko M, Tsutsumi M, Aikawa H, Matsumoto Y, Go Y, Nii K, et al. Distal protection filter device efficacy with carotid artery stenting : comparison between a distal protection filter and a distal protection balloon. Jpn J Radiol. 2013; 31:45–49. PMID: 23179785.

9. Kastrup A, Nägele T, Gröschel K, Schmidt F, Vogler E, Schulz J, et al. Incidence of new brain lesions after carotid stenting with and without cerebral protection. Stroke. 2006; 37:2312–2316. PMID: 16888277.

10. Kastrup A, Skalej M, Krapf H, Nägele T, Dichgans J, Schulz JB. Early outcome of carotid angioplasty and stenting versus carotid endarterectomy in a single academic center. Cerebrovasc Dis. 2003; 15:84–89. PMID: 12499716.

11. Macdonald S, Evans DH, Griffiths PD, McKevitt FM, Venables GS, Cleveland TJ, et al. Filter-protected versus unprotected carotid artery stenting : a randomised trial. Cerebrovasc Dis. 2010; 29:282–289. PMID: 20090320.

12. Maggio P, Altamura C, Landi D, Migliore S, Lupoi D, Moffa F, et al. Diffusion-weighted lesions after carotid artery stenting are associated with cognitive impairment. J Neurol Sci. 2013; 328:58–63. PMID: 23510565.

13. Montorsi P, Caputi L, Galli S, Ciceri E, Ballerini G, Agrifoglio M, 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; 58:1656–1663. PMID: 21982309.

14. Müller-Hülsbeck S, Schäfer PJ, Charalambous N, Schaffner SR, Heller M, Jahnke T. Comparison of carotid stents : an in-vitro experiment focusing on stent design. J Endovasc Ther. 2009; 16:168–177. PMID: 19456191.

15. Rapp JH, Wakil L, Sawhney R, Pan XM, Yenari MA, Glastonbury C, et al. Subclinical embolization after carotid artery stenting : new lesions on diffusion-weighted magnetic resonance imaging occur postprocedure. J Vasc Surg. 2007; 45:867–872. discussion 872-874PMID: 17376643.

16. SPACE Collaborative Group. Ringleb PA, Allenberg J, Brückmann H, Eckstein HH, Fraedrich G, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients : a randomised non-inferiority trial. Lancet. 2006; 368:1239–1247. PMID: 17027729.

17. Stabile E, Salemme L, Sorropago G, Tesorio T, Nammas W, Miranda M, et al. Proximal endovascular occlusion for carotid artery stenting : results from a prospective registry of 1,300 patients. J Am Coll Cardiol. 2010; 55:1661–1667. PMID: 20394868.

18. Taha MM, Maeda M, Sakaida H, Kawaguchi K, Toma N, Yamamoto A, et al. Cerebral ischemic lesions detected with diffusion-weighted magnetic resonance imaging after carotid artery stenting : comparison of several anti-embolic protection devices. Neurol Med Chir (Tokyo). 2009; 49:386–393. PMID: 19779282.

19. Takaya N, Yuan C, Chu B, Saam T, Polissar NL, Jarvik GP, et al. Presence of intraplaque hemorrhage stimulates progression of carotid atherosclerotic plaques : a high-resolution magnetic resonance imaging study. Circulation. 2005; 111:2768–2775. PMID: 15911695.

20. Voeks JH, Howard G, Roubin GS, Malas MB, Cohen DJ, Sternbergh WC 3rd, et al. Age and outcomes after carotid stenting and endarterectomy : the carotid revascularization endarterectomy versus stenting trial. Stroke. 2011; 42:3484–3490. PMID: 21980205.