Algorithmic selection of emboli protection device during the procedure of carotid artery stunting Yasuhiro Kawabata, Tetsuya Tsukahara, Shunichi Fukuda, Tomokazu Aoki, Satoru Kawarazaki Department of Neurosurgery, National Hospital Organization Kyoto Medical Center
background and purpose of this study Tailored-CAS algorithm has been advocated to decrease complication rate of carotid artery stenting (CAS) 1. Three different types of emboli protection devices (EPDs) are available in the Japanese market. Because each type of EPD has theoretical advantages and limitations, we made an algorithm in the selection of EPD. The purpose of this study is to verify the validity of our algorithm. 1 Piotr Pieniążek et al. Carotid artery stenting according to the tailored CAS algorithm is associated with a low complication rate at 30 days:data from the TARGET CAS study. Kardiol Pol 2012; 70, 4: 378 386
filter type EPDs FilterWire EZ SpiderFX Embolic Protection Device (filter type)
balloon-type EPD
proximal occlusive balloon type EPDs during predilatation Mo.Ma proximal cerebral protection device (Medtronic) FilterWireEZ Guardwire 9FrOptimo 9FrOptimo
Risk factors of cerebral embolism related to CAS siginal intensity ratio (SIR)! plaque volume High-Risk Plaque for Carotid Artery Stenting Evaluated With 3-Dimensional T1-Weighted Gradient Echo Sequence (Tanemura et al. Stroke 44, 105-110, 2013)
distal filter distal balloon proximal occlusive balloon advantage flow preservation 6Fr compatible easy to use 6Fr compatible vulnerable plaque vulnerable plaque throughout the procedure disadvantage vulnerable plaque x intolerance intolerance 9Fr compatible troublesome to use more expensive
Materials and methods Since 2012, CAS with EPDs was performed in 32 patients in our hospital. Twenty six patients were male, and 6 were female, and the median age is 72 years (64-89 years). There were 9 symptomatic lesions and 23 asymptomatic lesions. 19 patients (59%) were at high risk for carotid endarterectomy. The algorithm was based on the presence of neurological symptom, T1-weighted image of the carotid plaque, the collateral arterial supply, and the lesion length (as shown below).
characteristics of the patients sex comorbidity male 26 female 6 coronary artery disease 10 chronic kidney disease 6 age median 72 range 64-89 side left 15 right 17 degree of stenosis median 80 range 60-99 risk factors peripheral artery disease 14 malignancy 7 aortic dissection 1 abdominal aoritic aneurysm 1 clinical presentation asymptomatic 24 amaurosis fugax 1 transient ischemic attack 2 hemispheric stroke 5 HTN 26 DM 17 dyslipidemia 18 smoking 13
carotid plaque imaging T1WI high unknown T1WI intermediate T1WI low Carotid plaque imaging was routinely performed to identify the vulnerable plaque except two patients who had restenosis after carotid artery stenting. Echograhy was substituted in these patients.
procedures (1) premedication: single antiplatelet (2), double antiplatelet (24), triple antiplatelet (3), single antiplatelet+oral anticoagulant (1) double antiplatelet+oral anticoagulant (2) statin (22) systemic heparinization: activated clotting time>280 anesthesia: local approach:transfemoral 21, transbrachial 11 guiding catheter:6fr guiding sheath (19), 8Fr (6), 9Fr (7) stent: CarotidWall (16), Precise (13), Protege (3) predilatation was performed in 26 procedures. postdiltation was performed in 27 procedures.
EPDs FilterWireEZ MOMAultra SpiderRX Optimo Filter-type EPDs were used in 15 procedures (47%), and balloon-type EPDs were used in 11 procedures (34%). In 6 cases (19%), proximal endovascular blockage of blood flow was performed only during predilatation or throughout the procedures. In three patients with nearly occluded lesions and a patient in whom intraplaque hemorrhage was suspected by high intensity signal on time-offlight MR angiography1, proximal blockage was selected to prevent distal emboli during crossing of guiding wire or predilatation. 1 S. Yoshimura et al. Stroke. 2011;42:3132-3137 GuardWire
a list of patients in whom proximal endovascular blockage was used during the procedure age sex presentation % stenosis lesion length (mm) carotid plaque MRI EPD stent ischemic events 1 84 M asymptomatic 95 18 high Optimo +guardwire Carotid Wall DWI-high intensity lesions 2 70 F asymptomatic 99 70 low Optimo +guardwire PRECISE none 3 74 M symptomatic 80 20 high MOMAUltra Carotid Wall 4 67 M symptomatic 95 23 high MOMAUltra Carotid Wall none transient hemiparesis (after discharge) 5 75 M asymptomatic 85 14 high (intraplaque hemorrhage) Optimo +guardwire Carotid Wall DWI-high intensity lesions 6 85 M asymptomatic 95 15 high Optimo +FilterWireEZ Carotid Wall none
Carotid stenosis The presence of symptom asymptomatic symptomatic T1WI of the T1WI of the carotid plaque low~iso carotid plaque low~iso Collateral circulation Lesion length poor good <20mm >20mm Filter type EPD Distal balloon type EPD Proximal occlusive balloon EPD
result (1) thromboembolic events intraprocedural: asymptomatic infarction (occipital) 1/32 postprocedural: transient hemiparesis 1/32 (after discharge) hyperintense lesions on diffusion-weighted image: 16/32 (50%)
results (2) perioperative myocardial infarction: symptomatic (1), asymptomatic (2) exacerbation of chronic kidney disease: 1 procedure-related morbidity @ 30 day: 0 procedure-related mortality @ 30 day: 0
conclusion The present study showed that our algorithm in the selection of EPD can be a useful tool in the prevention of cerebral emboli during CAS.