Early Outcome of Carotid Angioplasty and Stenting With and Without Cerebral Protection Devices

Abstract

Background— Carotid angioplasty and stenting (CAS) is increasingly being used for treatment of symptomatic and asymptomatic carotid artery disease (CAD). To evaluate the efficacy of cerebral protection devices in preventing thromboembolic complications during CAS, we conducted a systematic review of studies reporting on the incidence of minor stroke, major stroke, or death within 30 days after CAS. Summary of Review— We searched for studies published between January 1990 and June 2002 by means of a PubMed search and a cumulative review of reference lists of all relevant publications. In 2357 patients a total of 2537 CAS procedures had been performed without protection devices, and in 839 patients 896 CAS procedures had been performed with protection devices. Both groups were similar with respect to age, sex distribution, cerebrovascular risk factors, and indications for CAS. In many studies the periprocedural complication rates had not been presented separately for patients with symptomatic and asymptomatic CAD. The combined stroke and death rate within 30 days in both symptomatic and asymptomatic patients was 1.8% in patients treated with cerebral protection devices compared with 5.5% in patients treated without cerebral protection devices (χ 2 =19.7, P <0.001). This effect was mainly due to a decrease in the occurrence of minor strokes (3.7% without cerebral protection versus 0.5% with cerebral protection; χ 2 =22.4, P <0.001) and major strokes (1.1% without cerebral protection versus 0.3% with cerebral protection; χ 2 =4.3, P <0.05), whereas death rates were almost identical (≈0.8%; χ 2 =0.3, P =0.6). Conclusions— On the basis of this early analysis of single-center studies, the use of cerebral protection devices appears to reduce thromboembolic complications during CAS. These technical aspects should be taken into account before the initiation of further randomized trials comparing CAS with carotid endarterectomy.

Iatrogenic vasospasm in carotid artery stent angioplasty with distal protection devices

“…13 The deployment of a stent in addition to angioplasty increases the occurrence of microembolic events as detected by transcranial Doppler sonography, 1 potentially increasing the risk of thromboembolic complications. A systematic review in 2003 found that DPD appeared to reduce the number of thromboembolic complications of CA stent placement, 10 a view that was confirmed by a review that incorporates the results of several trials that have been completed since. 22 While there seems to be an emerging consensus that CAS should only be performed with the use of DPDs, 14 data exist that points out the risks and potential adverse effects of the use of a DPD.…”

Carotid Plaque Echolucency Increases the Risk of Stroke in Carotid Stenting

“…20,25 Nevertheless, in the GSM Յ25 subset, BPDs did not seem to maintain their efficacy. It should be noted that the BPDs used in the different centers were almost exclusively distal BPDs (96% of the total), requiring the passage of the device across the lesion with the inherent risk of embolization.…”

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

“…[259][260][261][262] Contrast-induced nephropathy has been reported in <1% of cases, because CAS is generally avoided in patients with severe renal dysfunction. 263 The results of observational studies suggest that EPDs reduce rates of adverse events during CAS [264][265][266] when operators are experienced with the apparatus 56 ; in unfamiliar hands, the devices are associated with worse clinical outcomes 67,178,180 and a higher rate of stroke. 267 …”