Microembolization During Carotid Artery Stenting in Patients With High-Risk, Lipid-Rich Plaque

Montorsi, Piero; Caputi, Luigi; Galli, Stefano; Ciceri, Elisa; Ballerini, G; Agrifoglio, Marco; Ravagnani, Paolo; Trabattoni, Daniela; Pontone, Gianluca; Fabbiocchi, Franco; Loaldi, Alessandro; Parati, Eugenio; Andreini, Daniele; Veglia, Fabrizio; Bartorelli, Antonio L.

doi:10.1016/j.jacc.2011.07.015

Cited by 184 publications

(46 citation statements)

References 31 publications

(30 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Authors showed that deflation of proximal balloon occlusion was associated with higher microembolic signals counting than retrieval of filter devices. In addition to the results of Montorsi et al, 11 the worse results obtained in the flow-reversal group in the present study could be attributed to the larger diameter (9.5 Fr) of the GORE balloon sheath and its higher rigidity than the guiding catheter (7.0 Fr) used in the filter group. The larger size and the high rigidity of the GORE balloon sheath possibly increased shear stress in the artery walls during carotid catheterization, promoting the release of microemboli from plaques.…”

Section: Discussionsupporting

confidence: 47%

“…In this study, Montorsi et al 11 monitored all phases of the procedure and found lower incidence of microembolic signals with proximal balloon occlusion than that with filter protection in almost all phases of the procedure, except during the retrieval and deflation of devices. Authors showed that deflation of proximal balloon occlusion was associated with higher microembolic signals counting than retrieval of filter devices.…”

Section: Discussionmentioning

confidence: 57%

“…[11][12][13]17, Results of this review are summarized in Table 6. [11][12][13]17, The high variability in methods makes it difficult to compare between procedures and protection techniques accurately among the different studies reviewed. Accordingly, higher variable rates of ischemic brain lesions during CAS using several protection techniques and EPD can be seen in the reviewed studies.…”

Section: Downloaded Frommentioning

confidence: 99%

See 2 more Smart Citations

Flow Reversal Versus Filter Protection

Castro-Afonso

Abud

Rolo

et al. 2013

Circ: Cardiovascular Interventions

View full text Add to dashboard Cite

Background— Carotid artery stenting (CAS) has become an alternative treatment for patients presenting symptomatic carotid artery stenosis. The improvement in clinical outcomes with CAS has been associated with the development of embolic protection devices. The trial aim is to compare flow reversal versus filter protection during CAS through femoral access. Methods and Results— Patients were randomly enrolled in CAS using flow reversal or filter protection. The primary end points were the incidence, number, and size of new ischemic brain lesions after CAS. The secondary end points included major adverse cardiac and cerebrovascular events, transient ischemic attack, and definitive ischemic brain lesions on fluid-attenuated inversion recovery magnetic resonance image at a 3-month follow-up. Ischemic brain lesions were assessed by a 3T magnetic resonance image. Neurological outcomes were evaluated by means of the National Institutes of Health Stroke Scale and the modified Rankin Scale (mRS). Forty consecutive patients were randomly assigned. Compared with flow reversal (n=21), filter protection (n=19) resulted in a significant reduction in the incidence (15.8% versus 47.6%, P =0.03), number (0.73 versus 2.6, P =0.05), and size (0.81 versus 2.23 mm, P =0.05) of new ischemic brain lesions. Two patients, 1 from each group, presented transient ischemic attack at 3-month follow-up. There were no major adverse cardiac and cerebrovascular events in the hospital or at 3-month follow-up. Conclusions— In this small sample size trial, filter protection was more effective than flow reversal in reducing ischemic brain lesions during CAS through femoral approach. Clinical Trial Registration— URL: http://portal2.saude.gov.br/sisnep/ . Unique identifier: 0538.0.004.000-10.

show abstract

Section: Discussionsupporting

confidence: 47%

Section: Discussionmentioning

confidence: 57%

Section: Downloaded Frommentioning

confidence: 99%

See 1 more Smart Citation

Flow Reversal Versus Filter Protection

Castro-Afonso

Abud

Rolo

et al. 2013

Circ: Cardiovascular Interventions

View full text Add to dashboard Cite

show abstract

“…Only the degree of stenosis has still been employed as the most important inclusion criterion in these studies. However, it is well known that carotid artery stenting may often cause postprocedural lesions on diffusion-weighted MRI and/or ischemic stroke in patients with lipid-rich carotid plaque [45]. Therefore, the presented dual imaging approach may help the clinician to make a decision on therapeutic strategies and options with low morbidity and mortality.…”

Section: Discussionmentioning

confidence: 99%

Validity of Dual MRI and <sup>18</sup>F-FDG PET Imaging in Predicting Vulnerable and Inflamed Carotid Plaque

Saito

Kuroda

Hirata³

et al. 2013

Cerebrovasc Dis

View full text Add to dashboard Cite

Background: Vulnerable and inflamed plaques in the carotid artery are at high risk of ischemic stroke, suggesting the importance of diagnostic modalities to detect them in patients with carotid stenosis with high sensitivity and specificity. Although many investigators have reported that magnetic resonance imaging (MRI) is a useful tool to predict the vulnerable components of carotid plaque, its validity is not established. On the other hand, ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) may be an alternative modality to directly identify the inflamed plaque in carotid artery stenosis. Therefore, this study aimed at evaluating the validity of MRI and FDG-PET to predict vulnerable and inflamed carotid plaque. Methods: This prospective study totally included 25 patients who underwent carotid endarterectomy (CEA) for carotid artery stenosis at our institute between January 2009 and January 2012. Prior to CEA, FDG-PET, black-blood T1-weighted imaging (BB-T1WI), and 3-dimensional time-of-flight (TOF) imaging were performed. The specimens were stained with hematoxylin-eosin to assess the different plaque components (lipid, hemorrhage, calcification, and fibrous tissue). In addition, they were stained with primary antibodies against CD68 (activated macrophages) and matrix metalloproteinase (MMP)-9. Results: High FDG uptake was detected in 13 (52.0%) of 25 patients. All of them had lipid-rich plaque. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to identify the lipid-rich plaques were all 100% for FDG-PET. More importantly, all of the FDG-positive plaques had strong immunoreactivity against both CD68 and MMP-9. There was a significant correlation between the findings on FDG-PET and those on immunohistochemistry against CD68 and MMP-9 (p = 0.006 and 0.004, respectively). On the other hand, 16 (64.0%) of 25 patients had high signal intensity plaque on BB-T1WI. In 7 of these 16 patients, the lesions also showed high signal intensity on TOF imaging. All of them had a large intraplaque hemorrhage. The sensitivity, specificity, PPV, and NPV to identify a large intraplaque hemorrhage were 70, 100, 100, and 83%, respectively, for MRI. Conclusions: These findings suggest that FDG-PET and MRI are complementary to predict high-risk carotid plaque, such as lipid-rich or hemorrhagic plaque. FDG-PET can accurately predict the lipid-rich and inflamed plaque. MRI is valuable to identify unstable plaque with a large intraplaque hemorrhage. The combination of these two modalities may play an important role in predicting carotid plaque at high risk of ischemic stroke.

show abstract

“…Several studies have shown proximal protection devices to significantly reduce the perioperative microembolic signal detected by transcranial Doppler, and they also decrease the number of new ischemic lesions when compared to distal protection devices [4,5,6]. Traditionally, patients with a carotid lesion length >10 mm and/or angiographic string sign, a history of prior stroke or coronary artery disease, contralateral carotid stenosis >50%, older age, and female sex were reported to have a higher percentage of adverse outcomes and were also considered high-risk groups [7,8,9].…”

Section: Introductionmentioning

confidence: 99%

Safety Outcomes Using a Proximal Protection Device in Carotid Stenting of Long Carotid Stenoses

et al. 2016

View full text Add to dashboard Cite

Background: Embolic protection devices can prevent atherosclerotic emboli during carotid stenting. Newer proximal protection devices reverse flow in the internal carotid artery (ICA), leading to reduction in perioperative microemboli. The risk of stroke is high for carotid stenting of ICA lesions with a length >10 mm and/or angiographic string sign. Objective: We aimed to evaluate the safety outcomes of proximal embolic protection device usage in this high-risk group. Methods: This is a retrospective analysis of patients who underwent carotid stenting procedures with proximal embolic protection devices at a tertiary care center. High-risk features for adverse events with carotid stenting were identified. Peri- and postprocedural outcomes were recorded. We further compared outcomes in patients with a carotid stenosis length >10 mm to those with shorter stenosis. Results: From January 2011 to December 2014, we included 27 patients; 96.3% were symptomatic and 3.7% were asymptomatic. There was a stent placement technical success rate of 100%. No major stroke or coronary events were recorded. One minor stroke event developed in one patient. A carotid lesion length >10 mm and/or angiographic string sign was noted in 21/27 patients, with an average lesion length of 14.4 mm. One patient (4.8%) in this group developed a minor stroke event. Neither a coronary nor a major stroke event was recorded in this group. There was no significant difference in the complication rate between the long lesion and the control group. Conclusion: In our patient cohort, it was found that a proximal embolic protection device is safe for patients with carotid stenosis, including those with a carotid lesion length >10 mm and/or angiographic string sign.

show abstract

Microembolization During Carotid Artery Stenting in Patients With High-Risk, Lipid-Rich Plaque

Abstract: In patients with high-risk, lipid-rich plaque undergoing CAS, MO.MA led to significantly lower microembolization as assessed by using MES counts.

Cited by 184 publications

References 31 publications

Flow Reversal Versus Filter Protection

Flow Reversal Versus Filter Protection

Validity of Dual MRI and <sup>18</sup>F-FDG PET Imaging in Predicting Vulnerable and Inflamed Carotid Plaque

Safety Outcomes Using a Proximal Protection Device in Carotid Stenting of Long Carotid Stenoses

Contact Info

Product

Resources

About