Randomized Comparison of Distal and Proximal Cerebral Protection During Carotid Artery Stenting

Cano, Manuel; Kambara, Antônio Massamitsu; Cano, Silvia Judith Fortunato de; Portela, Luiz Antônio Pezzi; Paes, Ângela Tavares; Costa, J. Ribamar; Abizaid, Alexandre; Moreira, Samuel Martins; Sousa, Amanda G. M. R.; Sousa, J. Eduardo

doi:10.1016/j.jcin.2013.07.006

Cited by 51 publications

(26 citation statements)

References 21 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…In the short term, however, CAS is associated with a higher procedure-related and short-term (\30 days) risk of non-disabling stroke than CEA [5][6][7]. Diffusion-weighted magnetic resonance imaging (DW-MRI) demonstrated that about three times more patients have new ischaemic lesions in post-treatment scans after CAS than after CEA [4].…”

Section: Introductionmentioning

confidence: 99%

Incidence of New Ischaemic Brain Lesions After Carotid Artery Stenting with the Micromesh Roadsaver Carotid Artery Stent: A Prospective Single-Centre Study

Ruffino

Faletti²,

Bergamasco³

et al. 2016

Cardiovasc Intervent Radiol

View full text Add to dashboard Cite

Aims Several randomized trials of patients with carotid stenosis show increased adverse neurological events with stenting versus endarterectomy in the 30-day post-procedure. This study examines the incidence of new ischaemic lesions in patients treated in our centre using the new Roadsaver stent. Methods and results Between September 2015 and January 2016, 23 consecutive patients (age 74.3 ± 7.3 years, 17.4 % female) underwent carotid artery stenting with the Roadsaver stent, a nitinol double-layer micromesh device. A distal protection device was used in all cases. Diffusionweighted magnetic resonance imaging was performed 24 h before, and 24 h and 30 days after the procedure. The 24-h post-procedure imaging showed 15 new ipsilateral ischaemic lesions in 7 (30.4 %) patients: median volume 0.076 cm 3 (interquartile range 0.065-0.146 cm 3 ). All lesions were asymptomatic. The 30-day imaging showed complete resolution of all lesions and no new ischaemic lesions. Follow-up clinical and ultrasound examinations at 30 days and 6 months recorded no adverse cardiac or cerebrovascular events. Conclusions Protected stenting with micromesh Roadsaver stent showed good safety and efficacy in the treatment of carotid stenosis, with a low incidence of delayed embolic events and new ipsilateral ischaemic brain lesions. These preliminary results are encouraging, but need to be confirmed with larger populations.

show abstract

Section: Introductionmentioning

confidence: 99%

Incidence of New Ischaemic Brain Lesions After Carotid Artery Stenting with the Micromesh Roadsaver Carotid Artery Stent: A Prospective Single-Centre Study

Ruffino

Faletti²,

Bergamasco³

et al. 2016

Cardiovasc Intervent Radiol

View full text Add to dashboard Cite

show abstract

“…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).…”

Section: To the Editormentioning

confidence: 97%

“…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.…”

mentioning

confidence: 88%

See 1 more Smart Citation

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

Castro-Afonso

Abud

Rolo

et al. 2014

Circ: Cardiovascular Interventions

View full text Add to dashboard Cite

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. We agree with the authors in most of their comments and here address additional points with the aim of expanding available knowledge of the subject in focus.Stabile and Esposito considered that a lower experience of operator with flow-reversal device (12 cases versus >400 cases with filters) was the major factor associated with the poorer results obtained by the flow-reversal group of our trial.2 In fact, operator experience imbalances are usually an inherent limitation of interventional trials assessing new devices. Nevertheless, we are not completely convinced that it could definitively explain disparities among results. 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).Furthermore, Stabile and Esposito 1 conclude that the operator's experience imbalance of our study largely explain our final outcomes. 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.Another interesting finding that could influence discrepancies among studies was the premedication protocols of antiplatelet and heparin regimens. Although other studies used aspirin (100 mg/d), clopidogrel (75 mg/d), and unfractionated heparin (5000 UI bolus), [3][4][5] we indicated aspirin (300 mg/d), clopidogrel (75 mg/d), and unfractionated heparin (7500 UI bolus).2 Although we cannot prove that these differences among premedication protocols explain conflicting results, different premedication protocols have been suggested as a significant factor influencing outcomes. 6 Finally, small sample trials using a highly sensitive surrogate outcome measure tool may be associated with a high number of confounder factors and we think that the operator's experience is one of the most efficient embol...

show abstract

“…Nevertheless, 48 hours after distal fi lter or proximal occlusion, Cano et al [61] found new ischaemic cerebral lesions in > 60 % of patients. The vast majority of these lesions was small and did not result in clinical symptoms.…”

Section: Benefi T and Harm From Treatmentmentioning

confidence: 99%

Carotid stenosis – basing treatment on individual patients’ needs. Optimal medical therapy alone or accompanied by stenting or endarterectomy

Langhoff

2018

Vasa

View full text Add to dashboard Cite

Summary:Though carotid artery stenosis is a known origin of stroke, risk assessment and treatment modality are not yet satisfactorily established. Guideline updates according to latest evidence are expected shortly. Current clinical weakness concerns in particular the identifi cation of "at-risk" patients. Beside the symptomatic status and the degree of stenosis, further signs of unstable plaque on carotid and cerebral imaging should be considered. Moreover, medical and endovascular therapy are continuously improving. Randomized trials and meta-analyses have shown similar long-term results for protected carotid artery stenting and endarterectomy. However, endovascular revascularization was associated with an increased 30-day rate of minor strokes. Newly developed embolic protection devices could possibly compensate for this disadvantage. Furthermore, high-level optimal medical therapy alone is currently being evaluated comparatively. We assume that a comprehensive evaluation of plaque vulnerability, serious consideration of advanced embolic protection, and more space for optimal medical therapy alone according to latest evidence, will benefi t patients with carotid stenosis.Keywords: Carotid artery stenosis, carotid artery stenting, carotid endarterectomy, optimal medical therapy Risk of strokeIn neurologically symptomatic patients with carotid artery stenosis, in particular in those with a recent stroke or transient ischaemic attack (TIA), severe atherosclerosis is known to be associated with a high risk of recurrent stroke. In a recently published study [2], the recurrence rate of ipsilateral ischaemic stroke in patients with a degree of 50-99 % stenosis increased from 2.7 % within the fi rst day, to 5.3 % within three days, to 11.5 % within 14 days and fi nally to 18.8 % within 90 days after occurrence of neurologic symptoms. Advanced age and cerebral vs. ocular symptoms were associated with a higher recurrence rate. The survey did not reveal associations between the recurrence of neurological events and the degree of stenosis, additional vascular risk factors or medication. However, a large pooled data analysis [3] on symptomatic patients showed an increased benefi t from endarterectomy compared to medical treatment alone,

show abstract

Randomized Comparison of Distal and Proximal Cerebral Protection During Carotid Artery Stenting

Abstract: New ischemic lesions seen on DW-MRI were present in both groups in >60%, but the number of lesions per patient was greater in the ANGIOGUARD group. No death or disabling stroke occurred during at least 1 year of follow-up in both cohorts.

Cited by 51 publications

References 21 publications

Incidence of New Ischaemic Brain Lesions After Carotid Artery Stenting with the Micromesh Roadsaver Carotid Artery Stent: A Prospective Single-Centre Study

Incidence of New Ischaemic Brain Lesions After Carotid Artery Stenting with the Micromesh Roadsaver Carotid Artery Stent: A Prospective Single-Centre Study

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

Carotid stenosis – basing treatment on individual patients’ needs. Optimal medical therapy alone or accompanied by stenting or endarterectomy

Contact Info

Product

Resources

About