Diffusion-weighted magnetic resonance imaging in carotid angioplasty and stenting with balloon embolic protection devices.
ABSTRACT We compared the results of two procedures to protect against distal embolism caused by embolic debris from carotid angioplasty with stent deployment (CAS) using diffusion-weighted magnetic resonance imaging (MRI). The study group comprised 39 men and 3 women (42 and 3 CAS procedures, respectively) with severe carotid stenosis (average age 70.0 +/- 6.6 years). During 20 CAS procedures the internal carotid artery was protected with a single balloon. A PercuSurge GuardWire was used for temporary occlusion. During 25 CAS procedures the internal and external carotid arteries were simultaneously temporarily occluded with a PercuSurge GuardWire and a Sentry balloon catheter, respectively. Diffusion-weighted MRI was performed 1 to 3 days after CAS. Data from 26 patients undergoing conventional angiography for diagnosis of cerebral ischemic disease, cerebral aneurysm or brain tumors were included as controls. Diffusion-weighted MRI after conventional diagnostic angiography showed ischemic spots in 3 of the 26 controls (11.5%). Ischemic spots were observed during 11 of 20 CAS procedures with the internal carotid artery protected with a single balloon (55.0%), and were observed during 9 of 25 CAS procedures with both the internal and external carotid arteries protected (36.0%). This difference was significant (P = 0.0068). Ischemic lesions appeared not only ipsilateral to the carotid stenosis but also in the contralateral carotid artery (31.9%) and vertebrobasilar territory (25.3%). Better protection was obtained with simultaneous double occlusion of both the internal and external carotid artery than with single protection of the internal carotid artery during CAS.
Article: Cerebral ischemia detected with diffusion-weighted MR imaging after protected carotid artery stenting: comparison of distal balloon and filter device.[show abstract] [hide abstract]
ABSTRACT: The aim of this study was to examine the incidence of ischemia during protected carotid artery stenting (CAS) as well as to compare the protective efficacy of the balloon and filter devices on diffusion-weighted MR imaging (DWI). Seventy-one consecutive protected CAS procedures in 70 patients with a severe (> 70%) or symptomatic moderate (> 50%) carotid artery stenosis were examined. A balloon device (PercuSurge GuardWire) and a filter device (FilterWire EX/EZ, Emboshield) was used in 33 cases (CAS-B group) and 38 cases (CAS-F group) to prevent distal embolization, respectively. All the patients underwent DWI within seven days before and after the procedures. The number of new cerebral ischemic lesions on the post-procedural DWI were counted and divided into ipsilateral and contralateral lesions according to the relationship with the stenting side. New cerebral ischemic lesions were detected in 13 (39.4%) out of the 33 CAS-Bs and in 15 (39.5%) out of the 38 CAS-Fs. The mean number of total, ipsilateral and contralateral new cerebral ischemic lesion was 2.39, 1.67 and 0.73 in the CAS-B group and 2.11, 1.32 and 0.79 in the CAS-F group, respectively. No statistical differences were found between the two groups (p = 0.96, 0.74 and 0.65, respectively). The embolic complications encountered included two retinal infarctions and one hemiparesis in the CAS-B group (9.09%), and one retinal infarction, one hemiparesis and one ataxia in the CAS-F group (7.89%). There was a similar incidence of embolic complications in the two groups (p = 1.00). The type of distal protection device used such as a balloon and filter does not affect the incidence of cerebral embolization after protected CAS.Korean Journal of Radiology 8(4):276-85. · 1.54 Impact Factor
Article: Neuroprotection during carotid artery stenting using the GORE flow reversal system: 30-day outcomes in the EMPiRE Clinical Study.[show abstract] [hide abstract]
ABSTRACT: Each of the embolic protection devices used in carotid artery stenting (CAS) has advantages and disadvantages. The prospective, multicenter, single-arm EMPiRE Clinical Study investigated a proximally placed device (GORE Flow Reversal System) that provides distal neuroprotection during CAS by reversing blood flow in the internal carotid artery, thereby directing emboli away from the brain. The study evaluated 30-day outcomes in 245 pivotal high-surgical-risk patients (mean age, 70 years; 32% symptomatic; 16% ≥80-years old) with carotid stenosis who underwent CAS using the flow reversal system. The primary endpoint was a major adverse event (MAE; stroke, death, myocardial infarction, or transient ischemic attack) within 30 days of CAS. The MAE rate was compared with an objective performance criterion (OPC) derived from CAS studies that included embolic protection. The MAE rate was 4.5% (11 patients; P=0.002 compared with the OPC). The stroke and death rate was 2.9%. No patient had a major ischemic stroke. Six patients (2.4%) had intolerance to flow reversal. The death and stroke rates in the symptomatic, asymptomatic, and octogenarian subgroups were 2.6, 3, and 2.6%, respectively, meeting American Heart Association guidelines for carotid endarterectomy. The stroke and death rate in this study was among the lowest in CAS trials. The results indicate that the flow reversal system is safe and effective when used for neuroprotection during CAS and that it provides benefits in a broad patient population.Catheterization and Cardiovascular Interventions 02/2011; 77(3):420-9. · 2.29 Impact Factor