Carotid Artery Stenting: Utility of Cerebral Protection Devices
Carotid Artery Stenting: Utility of Cerebral Protection Devices
Neurologic deficits secondary to embolic events have been the most significant concern regarding carotid bifurcation stenting. Experimental studies utilizing human carotid plaques have shown that embolic particles were released from all specimens. In addition, transcranial Doppler studies have confirmed the fact that multiple emboli are released during each case. Preliminary experiences with the use of cerebral protection devices for carotid stenting have shown encouraging results with embolic particles recovered from each case, although these experiences have also revealed some of the down sides of its use. The present article provides the rationale for routine use of these protection devices and also reviews various protection devices, some of which are currently undergoing clinical trials.
Carotid artery balloon angioplasty with or without stenting (CBAS) has been investigated for the past two decades, primarily for the treatment of patients with carotid stenosis who have been considered to be at high risk for carotid endarterectomy (CEA). These patients include those with 1) previous history of CEA, 2) hostile neck secondary to radiation, total laryngectomy, or creation of a tracheotomy, 3) high lesions that are located above the mandible, low lesions below the clavicle, or 4) contralateral internal carotid artery (ICA) occlusion. Recently, the indication for CBAS has been expanded to include those that are not necessarily considered to be at high surgical risk. However, CBAS has not received wide acceptance primarily because of the availability of excellent results from CEA, and also due to the risk of embolic stroke associated with CBAS. The perioperative stroke/death rate following carotid CBAS ranges between 0.0-8.2%. These initial trial results have been criticized because of the high neurological complication rate.
Since it has been shown that the long-term patency and stroke prevention rates of carotid CBAS are promising, if perioperative stroke can be prevented, CBAS may gain popularity by virtue of its less invasive nature.
Neurologic deficits secondary to embolic events have been the most significant concern regarding carotid bifurcation stenting. Experimental studies utilizing human carotid plaques have shown that embolic particles were released from all specimens. In addition, transcranial Doppler studies have confirmed the fact that multiple emboli are released during each case. Preliminary experiences with the use of cerebral protection devices for carotid stenting have shown encouraging results with embolic particles recovered from each case, although these experiences have also revealed some of the down sides of its use. The present article provides the rationale for routine use of these protection devices and also reviews various protection devices, some of which are currently undergoing clinical trials.
Carotid artery balloon angioplasty with or without stenting (CBAS) has been investigated for the past two decades, primarily for the treatment of patients with carotid stenosis who have been considered to be at high risk for carotid endarterectomy (CEA). These patients include those with 1) previous history of CEA, 2) hostile neck secondary to radiation, total laryngectomy, or creation of a tracheotomy, 3) high lesions that are located above the mandible, low lesions below the clavicle, or 4) contralateral internal carotid artery (ICA) occlusion. Recently, the indication for CBAS has been expanded to include those that are not necessarily considered to be at high surgical risk. However, CBAS has not received wide acceptance primarily because of the availability of excellent results from CEA, and also due to the risk of embolic stroke associated with CBAS. The perioperative stroke/death rate following carotid CBAS ranges between 0.0-8.2%. These initial trial results have been criticized because of the high neurological complication rate.
Since it has been shown that the long-term patency and stroke prevention rates of carotid CBAS are promising, if perioperative stroke can be prevented, CBAS may gain popularity by virtue of its less invasive nature.
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