Transcervical carotid stenting with internal carotid artery flow reversal: Feasibility and preliminary results

Abstract

Transcervical CAS with carotid flow reversal is feasible and safe. It can be done with the patient under local anesthesia, averts the complications of the transfemoral approach, and eliminates the increased complexity and cost of cerebral protection devices. Transcervical CAS is feasible when the transfemoral route is impossible or contraindicated, and may be the procedure of choice in a subset of patients in whom carotid stenting is indicated.

Techniques for Optimizing Results in Carotid Stenting

“…It eliminates some of the complications associated with the transfemoral route, which include the hazards of wire and catheter manipulation in the aortic arch. In this setting, Criado et al described in 2004 a technique for transcervical CAS with flow reversal protection [65]. Although the experience is still small and prospective trials are needed, the short-term and long-term outcomes are also good and appear comparable with the reported results for carotid revascularization by endarterectomy [66,67].…”

The results of a simplified technique for safe carotid stenting in the elderly

“…[11][12][13][14][15][16] In the first technique, the carotid lesion is crossed unprotected, and in the second technique, one prolonged retrograde flow may produce brain damage. In a recent study, we have managed to reduce the time of flow reversal only for the time required to cross the ICA lesion for the insertion of the carotid filter (mean time 1.5 minutes) and this has made this technique applicable to patients with reduced intracranial collaterals and occlusion of the opposite ICA.…”

“…[9][10][11][12][13][14][15][16][17] Using this technique in a series of 48 octogenarians unsuitable for transfemoral CAS, Faraglia et al 9 has reported a 2.1% incidence of ischemic events and 13.8% incidence of intraoperative embolization rates, measured by diffusion-weighted-magnetic resonance imaging (DW-MRI). 9 Palombo et al 10 compared filter protected transcervical with transfemoral CAS and have found a significant decrease in transient ischemic attacks (TIAs) and stroke (2.3% vs 19.8%; P Ͻ .01), as well as postprocedure brain embolization in DW-MRI (14.3% vs 36.8%; P ϭ .015) after the transcervical procedure.…”

“…This technique has been applied to a relatively small number of patients with good clinical results in terms of ischemic events and mortality. [11][12][13][14][15][16] In the study of Leal et al, 16 with DW-MRI, performed in 30 patients before and after the procedure, silent new infarcts were found in only 12.5% (because new cerebral ischemic infarcts appear at rates of 37% after CAS and 10% after CEA, according to a systematic review of Schnaudigel et al 18 ). However, this procedure is applicable only if there is adequate brain perfusion from the opposite carotid and the vertebral arteries for a mean time of 15 to 22 minutes.…”

“…However, this procedure is applicable only if there is adequate brain perfusion from the opposite carotid and the vertebral arteries for a mean time of 15 to 22 minutes. [11][12][13][14][15][16]19 In a series of 76 patients undergoing carotid revascularization, Pipinos et al 19 have found that 9% of these patients had evidence of poor intracranial collaterals on magnetic resonance angiography (MRA) or computed tomography angiography (CTA) evaluation.…”