A diffusion-weighted magnetic resonance imaging-based study of transcervical carotid stenting with flow reversal vs transfemoral filter protection.
ABSTRACT BACKGROUND: Transfemoral carotid artery stenting (CAS) has been associated with a high incidence of embolic phenomena and silent brain infarction. The goal of this study was to compare the incidence of new ischemic cerebral lesions on diffusion-perfusion magnetic resonance imaging (MRI) sequences after transcervical CAS performed with carotid flow reversal vs stenting via transfemoral approach with distal filter protection. METHODS: During a 26-month period, 64 consecutive patients diagnosed with significant carotid stenosis by ultrasound imaging were assigned to transcervical CAS with carotid flow reversal or a transfemoral approach with a distal filter. The Rankin stroke scale was administered by an independent neurologist, and diffusion-weighted MRI (DW-MRI) studies were performed ≤24 hours before and ≤24 to 48 hours after the procedure. DW-MRI studies were compared by two neuroradiologists not involved in the study and blinded for time, clinical status, and treatment option. Hyperintense DW-MRI signals found after the procedure were interpreted as postoperative ischemic infarcts. All patients were assessed at 1, 6, and 12 months after the intervention. RESULTS: The distribution of demographic and pathologic variables was similar in both groups. All procedures were technically successful, with a mean carotid flow reversal time of 22 minutes. Twenty-one (70%) and 23 patients (69.69%) were symptomatic in the transcervical and transfemoral groups, respectively (P = .869). After intervention, new postprocedural DW-MRI ischemic infarcts were found in four transcervical (12.9%) and in 11 transfemoral (33.3%) patients (P = .03), without new neurologic symptoms. No major adverse events occurred at 30 days after the intervention. All patients remained neurologically intact, without an increase in stroke scale scoring. All stents remained patent, and all patients remained stroke-free during follow-up. In multivariate analysis, age (relative risk [RR], 1.022; P < .001), symptomatic status (RR, 4.109; P < .001), and open-cell vs closed-cell stent design (RR, 2.01; P < .001) were associated with a higher risk of embolization in the transfemoral group but not in the transcervical group. CONCLUSIONS: These data suggest that transcervical carotid stenting with carotid flow reversal carries a significantly lower incidence of new ischemic brain infarcts than that resulting from transfemoral CAS with a distal filter. The transcervical approach with carotid flow reversal may improve the safety of CAS and has the potential to improve results in especially vulnerable patients such as the elderly and symptomatic.
- SourceAvailable from: link.springer.com[Show abstract] [Hide abstract]
ABSTRACT: Carotid angioplasty and stenting (CAS) has emerged as a feasible and safe alternative for the management of extracranial carotid occlusive disease. The appropriate clinical setting, indications and techniques to maximize the benefit of this new approach are in constant evolution. The success of CAS relies not only on technique, device selection and management of complications but, maybe more importantly, on patient selection, peri-operative medical management and pre-procedural imaging and planning. The purpose of this review is to describe the peri-procedural and technical steps that can optimize the results of CAS.06/2013; 1(2). DOI:10.1007/s40137-013-0016-z
- [Show abstract] [Hide abstract]
ABSTRACT: Carotid artery stenting (CAS) is usually performed with femoral access; however, this access may be impeded by anatomic limitations. Moreover, many embolic events happen during aortic arch catheterization. To overcome these problems, transcervical access to the carotid artery can be used as an alternative approach for CAS. An electronic search of the literature using PubMed was performed. All studies reporting the results of CAS using the transcervical approach were retrieved and analyzed. The analysis included 12 studies reporting the results of 739 CAS procedures performed in 722 patients (mean age, 75.5 years). Of 533 lesions reported, 235 (44%) were symptomatic, with no data regarding symptomatic status available for 206 lesions. Two techniques were used: direct CAS with transcervical access (filter protected or unprotected) in 250 patients and CAS with transcervical access under reversed flow (with arteriovenous shunt in most cases) in 489 patients. Local anesthesia was used in 464 of 739 procedures (63%), and the remaining were performed under general anesthesia or cervical block. Technical success was 96.3% for 579 procedures with available data (558 successful procedures and 21 failures: inability to cross the lesion, 10; dissection, 5; failure of predilatation, 1; stent thrombosis, 1; patient agitation, 1; and no data, 3). The incidence of conversion to open repair was 3.0% (20 of 579 procedures: 18 carotid endarterectomies and two common carotid-internal carotid bypass grafts). Stroke occurred in eight patients (two fatal) and a fatal myocardial infarction in one patient. The incidence of stroke, myocardial infarction, and death was 1.1%, 0.14%, and 0.41%, respectively. The incidence of stroke was 1.2% (3 of 250) in direct CAS with transcervical access and 1.02% (5 of 489) in CAS under reversed flow (P = > .05). Transient ischemic attack occurred in 20 patients (2.7%). Local complications were encountered in 17 of 579 CAS (2.9%), comprising 15 hematomas and two patients with transient laryngeal palsy. CAS with the transcervical approach is a safe procedure with low incidence of stroke and complications. It can be used as an alternative to femoral access in patients with unfavorable aortoiliac or aortic arch anatomy.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 09/2013; 58(5). DOI:10.1016/j.jvs.2013.07.111 · 2.98 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: 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. http://circinterventions.ahajournals.org/content/6/5/552.fullCirculation Cardiovascular Interventions 10/2013; 6(5). DOI:10.1161/CIRCINTERVENTIONS.113.000479 · 6.98 Impact Factor