Operator’s Experience Is the Most Efficient Embolic Protection Device for Carotid Artery Stenting

Abstract

Stabile and Esposito Operator's Experience Determines CAS Outcomes 497reported a large unpredictability of data (the incidence of new postprocedural DW-MRI detected lesions ranged from 15.8% to 87.1%). Recent bench work evaluation of these 2 different filters demonstrated that they have a comparable ability to capture embolic particle and makes really difficult to explain that data variability. 10CAS outcomes are influenced by operators experience on the procedure itself and on the use of specific EPD. 11,12 Both the European studies are coming from catheterization laboratories with robust experience in carotid stenting performed with both proximal and distal EPDs. de Castro-Afonso et al 6 stated that they do have a good experience in distal protected CAS (450 CAS procedures in 10 years). This means ≈50 procedures per year, a number that is in accordance with current guidelines and should provide outcomes similar to those of high volume centers with well-experienced operators. 13 They also stated that they performed only 12 proximal protected procedures before starting randomization. It is clear that the amount of experience they have with the specific EPDs is not equal and is testified by the fact that the mean procedure time was longer when they used proximal protection. The authors explain this difference stating that flow-reversal device is more complex and requires more technical steps.Dissecting a CAS procedure, it becomes clear that there is a comparable complexity between a proximal protected and a distal protected one. A proximal protected CAS has 5 procedural steps (external carotid artery selective engagement, protection system placement, wiring of the lesion, stenting, and retrieval of the protection system). Comparably, a distal protected CAS also has 5 procedural steps (guiding catheter placement, wiring of the lesion with protection system, stenting, retrieval of the protection system, and retrieval of the guiding catheter).If we consider the authors' experience level on the use of proximal protection, it is clear that they are at the beginning of their learning curve on the use of proximal protection for CAS (<50 cases), 11 alternatively they have robust experience in performing distal protected CAS (>400 cases).12 From this difference of experience on the use of specific EPDs, it is sufficient to justify the discrepancy between their reported data and those available in the literature, coming from operators with bulky and similar experience on the use of both proximal and distal EPDs.At the end of our discussion, we have to conclude that de Castro-Afonso et al 6 presented interesting data and reminded us that it is still not clear at all which kind of EPD can provide the best cerebral protection. Looking at their data, operator's experience seems still to be the best protective factor for the brain of a patient undergoing CAS.A true randomized trial is needed now more than ever. This amount of conflicting results should be of stimulus for all physicians, scientists, and industry members involve...

Letter by de Castro-Afonso et al Regarding Article, “Operator’s Experience Is the Most Efficient Embolic Protection Device for Carotid Artery Stenting”

“…We appreciated the editorial by Stabile and Esposito, 1 where the authors made an extensive discussion on conflicting results between our trial and others previously published. [2][3][4] The authors' conjectures on these studies suggest that operator experience with carotid artery stenting procedures seems to be the best brain embolic protective factor.…”

“…The authors argued that our reported differences between flow-reversal and filter procedure times (22.41 versus 16.78 minutes; P<0.001) were in accordance with the lower operator's experience with the flow-reversal device. 1 However, in previous trials, the mean procedure times were also significantly longer with proximal than with distal protection devices 30 versus 22 minutes (P=0.003) and 29.5 versus 24.2 minutes (P=0.051) reported by Bijuklic et al 4 and Cano et al, 5 respectively, whereas Montorsi et al 3 did not report procedure times with the proximal protection group. Moreover, it is noteworthy that our mean procedure time with flow-reversal (22.41 minutes) was the shortest, which clearly contradicts Stabile's opinion.…”

“…Indeed, the authors reported that both the European studies come from centers with large experience in carotid artery stenting. 1 However, in a recent Brazilian study, that compared filter protection against the same proximal blockage device used in previous trials, 3,4 Cano et al 5 showed best results with the proximal blockage device, even with a lower operator's experience of the technique (13 cases).…”

Independent Modular Filter for Embolic Protection in Carotid Stenting

“…The limited compatibility of contemporary EPS with the array of 0.014″ guidewires may be reflected in the limitations of present CAS: (1) an extended operator's learning curve [17][18][19] ; (2) device-specific learning curve. Each EPD requires an individual learning curve; and (3) relationship between thromboembolic events and complex vascular geometries and high-risk lesion morphological features.…”

Carotid stenting versus endarterectomy for the treatment of carotid artery stenosis: Contemporary results from a large single center study

“…Multiple prospective studies and meta‐analyses have shown that higher‐volume operators (i.e., ≥ 6 cases per year) demonstrate lower rates of adverse complications, including stroke . At our hospital, there are three departments with privileges to perform CAS: IC, IR, and NS.…”