Silent Cerebral Ischemia Detected With Diffusion-Weighted Imaging in Patients Treated With Protected and Unprotected Carotid Artery Stenting

Cosottini, Mirco; Michelassi, Mc; Puglioli, Michele; Lazzarotti, G; Orlandi, Giovanni; Marconi, F; Parenti, G; Bartolozzi, Carlo

doi:10.1161/01.str.0000185676.05358.f2

Cited by 89 publications

(82 citation statements)

References 35 publications

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“…This result compares with the rate previously reported by Piñero et al 12 and improves the higher rates reported by others, 10,18 even if our preoperative and intraoperative antiplatelet and anticoagulation regimen differed slightly from that used in these other series. Of the 30 ischemic lesions detected by early postoperative DWI and followed over time, 18 lesions regressed, yielding a lesion reversibility rate of 60%.…”

Section: Discussionsupporting

confidence: 83%

Late Evaluation of Silent Cerebral Ischemia Detected by Diffusion-Weighted MR Imaging after Filter-Protected Carotid Artery Stenting

Palombo¹,

Faraglia²,

Stella³

et al. 2008

AJNR Am J Neuroradiol

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Section: Discussionsupporting

confidence: 83%

Late Evaluation of Silent Cerebral Ischemia Detected by Diffusion-Weighted MR Imaging after Filter-Protected Carotid Artery Stenting

Palombo¹,

Faraglia²,

Stella³

et al. 2008

AJNR Am J Neuroradiol

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“…22,23 However, selection bias and the use of historical controls might account for the observed differences in these non-randomised comparisons. In addition, it was not clear how ischaemic lesions on DWI relate to the risk of clinically apparent cerebrovascular events (stroke or TIA) associated with the intervention.…”

Section: Protocol Amendmentsmentioning

confidence: 99%

Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis

Featherstone

Dobson

Ederle

et al. 2016

Health Technol Assess

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BackgroundCarotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, but safety and long-term efficacy were uncertain.ObjectiveTo compare the risks, benefits and cost-effectiveness of CAS versus CEA for symptomatic carotid stenosis.DesignInternational, multicentre, randomised controlled, open, prospective clinical trial.SettingHospitals at 50 centres worldwide.ParticipantsPatients older than 40 years of age with symptomatic atheromatous carotid artery stenosis.InterventionsPatients were randomly allocated stenting or endarterectomy using a computerised service and followed for up to 10 years.Main outcome measuresThe primary outcome measure was the long-term rate of fatal or disabling stroke, analysed by intention to treat (ITT). Disability was assessed using the modified Rankin Scale (mRS). A cost–utility analysis estimating mean costs and quality-adjusted life-years (QALYs) was calculated over a 5-year time horizon.ResultsA total of 1713 patients were randomised but three withdrew consent immediately, leaving 1710 for ITT analysis (853 were assigned to stenting and 857 were assigned to endarterectomy). The incidence of stroke, death or procedural myocardial infarction (MI) within 120 days of treatment was 8.5% in the CAS group versus 5.2% in the CEA group (72 vs. 44 events) [hazard ratio (HR) 1.69, 95% confidence interval (CI) 1.16 to 2.45;p = 0.006]. In the analysis restricted to patients who completed stenting, age independently predicted the risk of stroke, death or MI within 30 days of CAS (relative risk increase 1.17% per 5 years of age, 95% CI 1.01% to 1.37%). Use of an open-cell stent conferred higher risk than a closed-cell stent (relative risk 1.92, 95% CI 1.11 to 3.33), but use of a cerebral protection device did not modify the risk. CAS was associated with a higher risk of stroke in patients with an age-related white-matter changes score of 7 or more (HR 2.98, 95% CI 1.29 to 6.93;p = 0.011). After completion of follow-up with a median of 4.2 years, the number of patients with fatal or disabling stroke in the CAS and CEA groups (52 vs. 49), and the cumulative 5-year risk did not differ significantly (6.4% vs. 6.5%) (HR 1.06, 95% CI 0.72 to 1.57;p = 0.776). Stroke of any severity was more frequent in the CAS group (15.2% vs. 9.4% in the CEA group) (HR 1.712, 95% CI 1.280 to 2.300;p < 0.001). There was no significant difference in long-term rates of severe carotid restenosis or occlusion (10.8% in the CAS group vs. 8.6% in the CEA group) (HR 1.25, 95% CI 0.89 to 1.75;p = 0.20). There was no difference in the distribution of mRS scores at 1-year, 5-year or final follow-up. There were no differences in costs or QALYs between the treatments.LimitationsPatients and investigators were not blinded to treatment allocation. Interventionists’ experience of stenting was less than that of surgeons with endarterectomy. Data on costs of managing strokes were not collected.ConclusionsThe functional outcome after stenting is similar to endarterectomy, but stenting is associated with a small increase in the risk of non-disabling stroke. The choice between stenting and endarterectomy should take into account the procedural risks related to individual patient characteristics. Future studies should include measurement of cognitive function, assessment of carotid plaque morphology and identification of clinical characteristics that determine benefit from revascularisation.Trial registrationCurrent Controlled Trials ISRCTN25337470.FundingThis project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 20. See the NIHR Journal Library website for further project information. Further funding was provided by the Medical Research Council, Stroke Association, Sanofi-Synthélabo and the European Union.

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“…Microembolic lesions detectable with diffusion-weighted imaging appeared in 26% of patients treated with a distal filter device versus 36% of patients treated with unprotected CAS. 8) A series of 162 CAS procedures involved distal ischemic events in 17.3% of patients, and the number of lesions per patient was 2.07, 23) compared to 2.8 in our study. However, all filtration devices have programmed pores to permit antegrade blood flow, which may allow particles smaller than the pore size to pass through the filter, and these Distal Ischemia After CAS small microemboli may not be visible using diffusion-weighted imaging.…”

Section: Discussionmentioning

confidence: 45%

“…8,32) Although cerebral protection devices have been developed and are widely used to prevent periprocedural cerebral embolization, their application may result in additional complications. 9,20) Cerebral ischemia can be significantly reduced by using protected CAS compared to unprotected procedures, 8,35) whereas favorable outcomes have been reported with unprotected CAS and most of the neurological complications could not have been prevented with protection devices. 25) Cerebral protection can be achieved by different devices including filter embolic protection devices, distal balloon occlusion devices, and proximal flow reverse protection devices.…”

Section: Introductionmentioning

confidence: 99%

Cerebral Ischemic Lesions Detected With Diffusion-Weighted Magnetic Resonance Imaging After Carotid Artery Stenting: Comparison of Several Anti-embolic Protection Devices

Taha

Maeda

Sakaida

et al. 2009

Neurol. Med. Chir.(Tokyo)

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Distal embolism is an important periprocedural technical complication with carotid angioplasty and carotid artery stenting (CAS). We evaluated the safety and efficacy of protection devices used during CAS by detecting new cerebral ischemic lesions using diffusion-weighted magnetic resonance imaging in 95 patients who underwent 98 CAS procedures: 34 using single PercuSurge GuardWire, 31 using double balloon protection, 15 using proximal flow reverse protection devices, 14 using Naviballoon, and 4 using filter anti-embolic devices. Diffusion-weighted imaging was performed preoperatively and postoperatively to evaluate the presence of any new embolic cerebral lesions. Postoperative diffusionweighted imaging revealed 117 new ischemic lesions. Three patients had new ischemic stroke, two minor and one major, all ipsilateral to the treated carotid artery. The remaining patients had clinically silent ischemia. The incidence of new embolic lesions was lower using the proximal flow reverse protection device than with the double balloon protection (33% vs. 48.4%), but the volume of ipsilateral new ischemic lesions per patient was 136.6 mm 3 vs. 86.9 mm 3 , respectively. Neuroprotection with Naviballoon yielded ipsilateral lesions of large volume (86.6 mm 3 ) and higher number (5.7 lesions per patient) than using the filter anti-embolic device (34.8 mm 3 and 1 lesion per patient). New cerebral ischemic lesions after neuroprotected CAS are usually silent. The lower incidence of distal ischemia using proximal flow reverse and double balloon protection devices is limited by the larger volume and higher number of ischemic lesions.

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Silent Cerebral Ischemia Detected With Diffusion-Weighted Imaging in Patients Treated With Protected and Unprotected Carotid Artery Stenting

Cited by 89 publications

References 35 publications

Late Evaluation of Silent Cerebral Ischemia Detected by Diffusion-Weighted MR Imaging after Filter-Protected Carotid Artery Stenting

Late Evaluation of Silent Cerebral Ischemia Detected by Diffusion-Weighted MR Imaging after Filter-Protected Carotid Artery Stenting

Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis

Cerebral Ischemic Lesions Detected With Diffusion-Weighted Magnetic Resonance Imaging After Carotid Artery Stenting: Comparison of Several Anti-embolic Protection Devices

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