Background and Purpose-Protection devices are increasingly used in carotid artery stenting. However, no randomized trial has been conducted to evaluate the efficacy of such devices, and arguments have also been formulated against their routine use. We set out to investigate the complication rates associated with carotid artery stenting performed without protection devices. Applicability of covered stents in the carotid system was also evaluated. Methods-Between

Objectives A higher rate of embolization is considered a disadvantage of carotid stenting (CAS), when compared with carotid endarterectomy. Plaques in the aortic arch (AA) and the common carotid artery (CCA) may be additional sources of embolization to stented internal carotid plaques during CAS. In this study, we aimed to investigate the relationship between these plaques and intracerebral embolization. Methods We analyzed the occurrence and composition of plaques in the AA and CCA by computed tomography angiography (CTA) in 101 consecutive cases of CAS. Cases of peri-procedural embolization were detected on diffusion-weighted imaging as lesions demonstrating diffusion restriction. We applied the χ2 and Fisher’s exact tests, as well as logistic regression models. Results The occurrence of plaques in the AA and CCA was significantly related to the appearance of new diffusion-weighted imaging lesions ( p = 0.013 and p = 0.004, respectively). Patients with soft plaques in the AA or CCA had a significantly higher risk of embolization than those without plaques ( p = 0.012 and p = 0.006, respectively). In contrast, homogeneously calcified plaques did not pose significantly higher risks. Conclusions Soft plaques in the AA and CCA result in a substantial risk of embolization during CAS. Use of a CTA examination of the AA and the CCA in patients with carotid stenosis may help to select lower-risk patients for CAS.

Covered stents provide efficient peri- and post-procedural protection against neurological complications due to embolisation from high-risk plaques during carotid artery stenting. Restenosis of covered stents appears to be infrequent during long-term follow-up.

AA aortic arch ADC apparent diffusion coefficient BMS bare metal stent CAS carotid artery stenting CCA common carotid artery CEA carotid endartrectomy CTA computed tomography angiography DSA digital subtraction angiography DWI diffusion weighted imaging ECA external carotid artery EPD embolic protection device F French HITS high intensity transient signals ICA internal carotid artery MES microembolic signal MI myocardial infarction MRI magnetic resonance imaging OTW over the wire POD proximal occlusion device PTA percutaneous transluminal angioplasty PTFE poly-tetra-fluor-ethylene SDS stent delivery system TCD Transcranial Doppler Ultrasound TIA transient ischaemic attack