Cerebral Protection During Carotid Stenting Using Flow Reversal

Parodi, Juan C.; Ferreira, Luis Mariano; Sicard, Gregorio A.; Mura, Ricardo La; Fernandez, Stéphanie

doi:10.1016/j.accreview.2005.06.063

Cited by 14 publications

(19 citation statements)

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“…This technique has been shown to reduce embolic signals detected by TCD. 13 However, the length and caliber of the protection catheter produces a high resistance that limits the arteriovenous gradient and therefore hampers the reversal flow. Other potential complications of the transfemoral approach include embolization from the aortic arch, supraaortic trunk instrumentation, and technical difficulty resulting from tortuous supraaortic trunks or occlusive disease of aortiliac or femoral arteries.…”

Section: Discussionmentioning

confidence: 99%

Transcranial Doppler Monitoring of Transcervical Carotid Stenting With Flow Reversal Protection

Ribó

Molina

Alvarez

et al. 2006

Stroke

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Background and Purpose-Transfemoral carotid stenting, despite becoming very frequent, has some limitations such as difficult groin access in few patients, lack of distal protection during filter placement, or embolization despite protection. Transcervical stenting (TCS) is a novel technique during which a common carotid to jugular vein shunt is placed creating a protective reversal flow in the internal carotid artery after proximal common carotid artery (CCA) clamping. We aim to study, with transcranial Doppler (TCD), cerebral flow changes and microemboli detection during transcervical stenting. Methods-From September 2005 to March 2006, of 65 consecutive patients eligible for carotid revascularization, 23 were considered high risk (sapphire criteria) and underwent TCS. Neurologic examination was performed before and after the procedure by a neurologist and a preprocedure vascular reactivity TCD examination was done in all patients. Results-After CCA clamping, flow inversion was observed in the anterior cerebral artery, supplying blood to the middle cerebral artery (MCA) and internal carotid artery (reversal). TCD did not detect any air/solid emboli during stent deployment and angioplasty confirming the reversal flow protection hypothesis. Mean reversal flow time was 15.4 minutes; in all cases, substantial MCA flow was present during CCA clamping (initial mean velocity 30 cm/s), and a slow gradual increase was observed traducing collateral flow recruitment (mean velocity after 5 minutes 36 cm/s, PϽ0.001). Flow increase was observed in all patients except in those with preprocedural exhausted ipsilateral vascular reactivity (16% versus 2%, Pϭ0.036). The only in-procedure complication was one transient ischemic attack. After CCA unclamping, normal antegrade flow was restored in anterior cerebral artery and mean final MCA velocity increased 16% according to preprocedure flow. Conclusions-TCS with protective internal carotid artery flow reversal can eliminate showers of micoremboli during stent deployment making it a promising carotid revascularization technique in high-risk patients with carotid stenosis.

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Section: Discussionmentioning

confidence: 99%

Transcranial Doppler Monitoring of Transcervical Carotid Stenting With Flow Reversal Protection

Ribó

Molina

Alvarez

et al. 2006

Stroke

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“…To prevent distal cerebral vessel emboli, proximal protection, distal protection, or a combination of these was used. The technique for proximal protection has been previously described 13 . Once the distal ICA lumen was secured, distal protection was applied in all cases using GuardWire (Medtronic, Minneapolis, MN, uSA).…”

Section: Introductionmentioning

confidence: 99%

Wire-Probing Technique to Revascularize Subacute or Chronic Internal Carotid Artery Occlusion

Namba

Shojima²,

Nemoto

2012

Interv Neuroradiol

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During endovascular revascularization of subacute and chronic occlusion of the cervical internal carotid artery (ICA) it may be difficult to penetrate the lesion. Selecting the appropriate “true lumen”, a remnant of what had been the arterial lumen, at the initial step may facilitate the procedure. Because plaque at the carotid bifurcation is known to propagate from the posterior wall, a gateway to this “true lumen” should exist in the anterior side of the occluded stump. This hypothesis was studied retrospectively in our series of revascularizing ICA subacute and chronic occlusion. Eleven patients underwent endovascular revascularization for symptomatic cervical ICA occlusion. Procedures were performed by initially penetrating the occluded stump with a guidewire, followed by supporting catheter advancement through the occluded segment to secure the distal normal arterial lumen. Cases were analyzed with regard to the location of initial guidewire penetration. Eight patients underwent successful revascularization. In five cases, the entry point to the occluded stump was located at the anterior side, and in three, at the posterior side. Two posterior stump penetration cases were met with resistance in guidewire advancement, whereas penetration was smooth in the anterior cases. In addition, two posterior stump penetration cases resulted in contrast stasis in the posterior ICA wall. In our series of revascularizing cervical ICA subacute and chronic occlusion, initially targeting the anterior side of the occluded stump resulted in favorable results. This may be the result of selecting the “true lumen” at the beginning of the procedure.

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“…These areas are very fragile, and plaque hemorrhage can easily occur. 7) Evaluation of neovascularization is therefore important in assessing plaque instability. While CEUS shows neovascularization, intra-plaque hemorrhage and large lipid cores are evaluated as unstable plaque on MRI.…”

Section: Resultsmentioning

confidence: 99%

Use of Contrast-enhanced Carotid Ultrasonography in Preoperative Assessment for Carotid Artery Stenting

Hagiwara

Takada

Shimizu

et al. 2018

JNET

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Objective: Contrast-enhanced carotid ultrasonography (CEUS) is a new technique for assessing carotid artery plaques.The present study attempted to demonstrate the association between the findings of CEUS performed prior to carotid artery stenting (CAS) and plaque debris caught during CAS. Methods:This study was conducted with 16 patients (15 men, 1 woman; mean age: 74.8 years) who had undergone evaluation of carotid plaque vulnerability followed by CAS. The carotid plaque evaluation consisted of CEUS and MRI.The amount of debris retrieved during CAS was semi-quantitatively classified into three grades (large, moderate, and small) by three independent physicians based on inspection of photographs of retrieved debris. The existence of a correlation between CEUS findings and the amount of debris was examined.Results: Enhanced plaque on CEUS was observed in 7 of 16 patients. A large amount of debris was observed during CAS in four of the seven patients with CEUS-enhanced plaques that were also assessed as unstable on MRI, while two patients had a moderate amount and one patient had a small amount of debris. There were significant correlations between the amount of debris and plaque enhancement on CEUS, unstable plaque on MRI, and enhancement of plaque on CEUS with unstable plaque on MRI (p = 0.036, p = 0.029, p = 0.036, respectively). For the prediction of moderate to large amount of debris occurring in CAS, enhancement of plaque demonstrated by CEUS had a sensitivity of 66.7% and a specificity of 85.7%, unstable plaque determined by MRI had a sensitivity of 100% and a specificity of 42.9%, and enhancement of plaque by CEUS and unstable plaque determined by MRI had a sensitivity of 100% and a specificity of 75%. Conclusion:Plaque vulnerability assessment using the combination of CEUS and MRI can predict the amount of debris retrieved during CAS, while using CEUS alone proved to be insufficient.

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Cerebral Protection During Carotid Stenting Using Flow Reversal

Cited by 14 publications

References 0 publications

Transcranial Doppler Monitoring of Transcervical Carotid Stenting With Flow Reversal Protection

Transcranial Doppler Monitoring of Transcervical Carotid Stenting With Flow Reversal Protection

Wire-Probing Technique to Revascularize Subacute or Chronic Internal Carotid Artery Occlusion

Use of Contrast-enhanced Carotid Ultrasonography in Preoperative Assessment for Carotid Artery Stenting

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