Carotid Artery Angioplasty and Stenting Without Distal Embolic Protection Devices

Binning, Mandy J.; Maxwell, Christina R.; Stofko, Douglas L.; Zerr, Myra; Maghazehe, Kamyar; Liebman, Kenneth; Hakma, Zakaria; Lewis-Diaz, Cynthia; Veznedaroglu, Erol

doi:10.1227/neu.0000000000001367

Cited by 7 publications

(11 citation statements)

References 13 publications

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“…No fatal major strokes or death were related to the procedure. This low incidence of minor stroke (1.8%) compares favorably with those reported in other major trials including the study by Kastrup et al [7] and most recently Binning et al [11]. In the former, a rate of 1.8 and 5.5% was reported for those treated with and without EPD, respectively.…”

Section: Discussionsupporting

confidence: 86%

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Carotid Revascularization with and without the Use of an Embolic Protection Device: A Single-Center Experience from Pakistan

Bashir

Baig

2018

Intervent Neurol

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Background: To assess the safety and clinical efficacy of carotid artery stenting with and without an embolic protection device (EPD) in both symptomatic and asymptomatic carotid disease cases. Methods: Retrospective data of 55 symptomatic (≥50% occlusion by digital subtraction angiography [DSA], ≥70% by ultrasound, computed tomography angiography [CTA], and magnetic resonance angiography [MRA]) and asymptomatic (≥60% by DSA, ≥70% by ultrasound, ≥80% by CTA and MRA) carotid disease cases undergoing carotid stenting/angioplasty revascularization from February 2014 to October 2017 was reviewed. All symptomatic patients either experienced recurrent transient ischemic attacks or one or more stroke attacks. An EPD protocol was designed for its selective use based on plaque morphologies and working diameters. The primary end points at 30 days of follow-up were a periprocedural incidence of any stroke, myocardial infarction or death, and ipsilateral stroke during the follow-up period. Results: Of the 55 cases, 39 were males and 16 females; mean age was 64.8 years. Fifty-one patients (92.7%) were symptomatic, with a mean stenosis of 80.1%. EPD was used in only 11 cases (20%). Minor stroke rate during the first 30 postoperative days was 1.8% (1 case) with EPD; no myocardial infarction or mortality. No stroke occurred during the median 1.5 years’ follow-up. Conclusion: Based on our single-center experience and findings of a relatively small sample size, carotid revascularization with stenting and angioplasty without EPD in experienced hands was found to be safe and efficacious. In addition, it proves cost-effective for patients by limiting the use of unnecessary disposables. These results are comparable to those reported in major trials and are well within the complication thresholds suggested in current guidelines. These results also show promise and illustrate the need for a larger, randomized controlled trial in order to thoroughly address this aspect of carotid revascularization.

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Section: Discussionsupporting

confidence: 86%

“…The use of an EPD adds to manipulation and hence apart from adding to the cost, it increases procedural risks [9]. Maynar et al [10], and most recently Binning et al [11] in their cases of CAS without EPD, showed that the placement of a stent before or after balloon dilation was both safe and efficacious.…”

Section: Introductionmentioning

confidence: 99%

Carotid Revascularization with and without the Use of an Embolic Protection Device: A Single-Center Experience from Pakistan

Bashir

Baig

2018

Intervent Neurol

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“…At the same time, studies on CAS without protection are few in the modern stent era or are a subanalysis of larger studies. [13][14][15][16][17][18][19] Our CAS experience began with the routine use of different types of distal filters in all procedures. After more than 200 filters were found empty on visual examination, we began doubting the role of the filter in our practice: was it fundamental to the success and the safety of our patients?…”

Section: Discussionmentioning

confidence: 99%

Carotid Artery Stenting Without Embolic Protection Device: A Single-Center Experience

et al. 2018

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To evaluate the safety and efficacy of carotid artery stenting (CAS) performed without an embolic protection device (EPD) in a selected group of asymptomatic patients with primary internal carotid artery (ICA) stenosis or restenosis after carotid endarterectomy (CEA). Materials and Methods: Between May 2015 and May 2018, 77 patients (mean age 77 years; 60 men) underwent CAS without any embolic protection device. Forty-seven (61%) patients had primary ICA stenosis and were excluded from CEA because of high surgical risk; the other 30 (39%) patients had post-CEA restenosis (n=26) or a distal ICA flap after eversion CEA (n=4). The mean ICA stenosis was 82%. All procedures were performed from a femoral artery access. Pre-and/or postdilation were used in 64 patients. The primary outcome was the incidence of major complications (death, stroke, or myocardial infarction) during the procedure and within 30 days; the secondary outcome was the incidence of restenosis in follow-up. Results: No relevant bradycardia was encountered during CAS. The combined rate of stroke, death, or myocardial infarction at 30 days was 1.3%. The single stroke patient recovered fully after 2 months. Over a follow-up that ranged to 3 years (mean 24±18 months), no further neurological events were recorded. One (1.3%) patient had a >70% restenosis after 6 months; the lesion was dilated, successfully restoring the lumen contour. Conclusion: In our series, endovascular treatment of carotid stenosis without the use of protection devices in patients with primary stenosis or postsurgical restenosis can achieve satisfactory safety and efficacy outcomes. The choice of performing CAS without using EPDs should follow a tailored approach based on the appropriate patient anatomy and specific clinical parameters to minimize neurological complications.

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“…The evolution of modern case series has been toward higher volumes and lower complications in the spirit of concluding that a device or treatment approach is "safe" and "effective" [6,7]. While these series may suggest technical prowess of the treating practitioners, there is often much that can be gleaned from patients that do not suffer obvious or "permanent" complications.…”

Section: Discussionmentioning

confidence: 99%

Neurointerventional “Near Morbidity”: A Candid Appraisal of an Early Case Series

et al. 2018

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Background: Modern case series often focus on emphasizing low complication rates, “safety,” and “efficacy.” Although patients may not suffer significant or obviously apparent neurological complications, many lessons are buried in the “no complications” cohort. Methods: The junior author’s prospectively maintained caselog was reviewed over a 1-year period for both symptomatic and “minor”/technical complications of neurointerventional cases, the latter referring to an intraprocedural inability to treat a lesion, suboptimal result, or potentially morbid angiographic occurrence/finding that did not result in permanent neurological morbidity – neurointerventional “near morbidity” (NNM). Results: Of 602 treatments performed over the reviewed period, 163 were interventional neuroendovascular procedures. The most common neuroendovascular procedure performed was stroke thrombectomy (67 cases). Major neurological complications, defined as symptomatic stroke or hemorrhage, occurred in 7 cases (4%). NNM, consisting of instructive, technical issues arose in an additional 9 cases that did not result in neurological morbidity (6%). Overall, in 20/163 cases (12%), there were either major neurological complications, NNM, groin complications, or major medical complications. Conclusions: “Minor”/technical complications – NNM – can be as instructive and illustrative as major complications despite not resulting in permanent morbidity. In reviewing case series, particularly early in one’s career, these cases should be highlighted.

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Carotid Artery Angioplasty and Stenting Without Distal Embolic Protection Devices

Cited by 7 publications

References 13 publications

Carotid Revascularization with and without the Use of an Embolic Protection Device: A Single-Center Experience from Pakistan

Carotid Revascularization with and without the Use of an Embolic Protection Device: A Single-Center Experience from Pakistan

Carotid Artery Stenting Without Embolic Protection Device: A Single-Center Experience

Neurointerventional “Near Morbidity”: A Candid Appraisal of an Early Case Series

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