Transcervical Carotid Stenting With Dynamic Flow Reversal Demonstrates Embolization Rates Comparable to Carotid Endarterectomy
Abstract
Purpose: To evaluate a series of patients treated electively with carotid endarterectomy (CEA), transfemoral carotid artery stenting with distal filter protection (CASdp), and transcervical carotid stenting with dynamic flow reversal (CASfr) monitored continuously with transcranial Doppler (TCD) during the procedure to detect intraoperative embolization rates. Methods: Thirty-four patients (mean age 67.6 years; 24 men) with significant carotid stenosis underwent successful TCD monitoring during the revascularization procedure (10 CEA, 8 CASdp, and 16 CASfr). Ipsilateral microembolic signals were segregated into 3 phases: preprotection (until internal carotid artery cross-shunted or clamped if no shunt was used, filter deployed, or flow reversal established), protection (until clamp/shunt was removed, filter retrieved, or antegrade flow reestablished), and postprotection (after clamp/shunt or filter removal or restoration of normal flow). Results: CASdp showed higher embolization rates than CEA or CASfr in the preprotection phase (p<0.001). In the protection phase, CASdp was again associated with more embolization compared with CEA and CASfr (p<0.001). In the postprotection phase, no differences between the revascularization therapies were observed. CASfr and CEA did not show significant differences in intraoperative embolization during any of the phases. Conclusion: TCD recordings demonstrated a significant reduction in embolization to the brain during transcervical carotid artery stent placement with the use of dynamic flow reversal compared to transfemoral CAS using distal filters. No significant differences in microembolization could be detected between CEA and CASfr. The observed lower embolization rates and lack of adverse events suggest that transcervical CAS with dynamic flow reversal is a promising technique and may be the preferred method when performing CAS.
Get full access to this article
View all access and purchase options for this article.
References
1. Taylor DW. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325:445–453.
2. Halliday A, Mansfield A, Marro J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004;363:1491–1502.
3. Schnaudigel S, Groschel K, Pilgram SM, et al. New brain lesions after carotid stenting versus carotid endarterectomy—a systematic review of the literature. Stroke. 2008;39:1911–1919.
4. Bijuklic K, Wandler A, Hazizi F, et al. The PROFI study (prevention of cerebral embolization by proximal balloon occlusion compared to filter protection during carotid artery stenting): a prospective randomized trial. J Am Coll Cardiol. 2012;59:1383–1389.
5. Goode SD, Hoggard N, Macdonald S, et al. Assessment of reverse flow as a means of cerebral protection during carotid artery stent placement with diffusion-weighted and transcranial Doppler imaging. J Vasc Interv Radiol. 2013;24:528–533.
6. Pinter L, Ribo M, Loh C, et al. Safety and feasibility of a novel transcervical access neuroprotection system for carotid artery stenting in the proof study. J Vasc Surg. 2011;54:1317–1323.
7. Leal I, Orgaz A, Flores A, et al. A diffusion-weighted magnetic resonance imaging-based study of transcervical carotid stenting with flow reversal versus transfemoral filter protection. J Vasc Surg. 2012;56:1585–1590.
8. Flores A, Doblas M, Criado E. Transcervical carotid artery stenting with flow reversal eliminates emboli during stenting: why does it work and what are the advantages with this approach. J Cardiovasc Surg. 2009;50:745–749.
9. Stroobant N, Vingerhoets G. Transcranial Doppler ultrasonography monitoring of cerebral hemodynamics during performance of cognitive tasks: a review. Neuropsychol Rev. 2000;10:213–231.
10. Ringelstein EB, Droste DW, Babikian VL, et al. Consensus on microembolus detection by TCD. Stroke. 1998;29:725–729.
11. Gupta N, Corriere MA, Dodson TF, et al. The incidence of microemboli to the brain is less with endarterectomy than with percutaneous revascularization with distal filters or flow reversal. J Vasc Surg. 2011;53:316–322.
12. Crawley F, Stygall J, Lunn S, et al. Comparison of microembolism detected by transcranial Doppler and neuropsychological sequelae of carotid surgery and percutaneous transluminal angioplasty. Stroke. 2000;31:1329–1334.
13. Bendszus M, Stoll G. Silent cerebral ischaemia: hidden fingerprints of invasive medical procedures. Lancet Neurol. 2006;5:364–372.
14. Ribo M, Molina CA, Alvarez B, et al. Transcranial Doppler monitoring of transcervical carotid stenting with flow reversal protection - a novel carotid revascularization technique. Stroke. 2006;37:2846–2849.
15. Lorenz MW, Gonzalez M, Lienerth C, et al. Influence of temporal insonation window quality on the assessment of cerebral autoregulation with transcranial Doppler sonography. Ultrasound Med Biol. 2007;33:1540–1545.
16. Marinoni M, Ginanneschi A, Forleo P, et al. Technical limits in transcranial Doppler recording: Inadequate acoustic windows. Ultrasound Med Biol. 1997;23:1275–1277.
17. Lo CH, Doblas M, Criado E. Advantages and indications of transcervical carotid artery stenting with carotid flow reversal. J Cardiovasc Surg. 2005;46:229–239.
18. Bladin CF, Bingham L, Grigg L, et al. Transcranial Doppler detection of microemboli during percutaneous transluminal coronary angioplasty. Stroke. 1998;29:2367–2370.
19. Jansen C, Vriens EM, Eikelboom BC, et al. Carotid endarterectomy with transcranial Doppler and electroencephalographic monitoring—a prospective-study in 130 operations. Stroke. 1993;24:665–669.
20. Hammer FD, Lacroix V, Duprez T, et al. Cerebral microembolization after protected carotid artery stenting in surgical high-risk patients: results of a 2-year prospective study. J Vasc Surg. 2005;42:847–853.
21. Vos JA, van den Berg JC, Ernst SM, et al. Carotid angioplasty and stent placement: comparison of transcranial Doppler US data and clinical outcome with and without filtering cerebral protection devices in 509 patients. Radiology. 2005;234:493–499.
22. Macdonald S, Evans DH, Griffiths PD, et al. Filter-protected versus unprotected carotid artery stenting: a randomised trial. Cerebrovasc Dis. 2010;29:282–289.
23. Cosottini M, Michelassi MC, Puglioli M, et al. Silent cerebral ischemia detected with diffusion-weighted imaging in patients treated with protected and unprotected carotid artery stenting. Stroke. 2005;36:2389–2393.
24. Bonati LH, Jongen LM, Haller S, et al. New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol. 2010;9:353–362.
25. Müller-Hülsbeck S, Jahnke T, Liess C, et al. In vitro comparison of four cerebral protection filters for preventing human plaque embolization during carotid interventions. J Endovasc Ther. 2002;9:793–802.
26. Macdonald S. The evidence for cerebral protection: an analysis and summary of the literature. Eur J Radiol. 2006;60:20–25.
27. Ansel GM, Hopkins LN, Jaff MR, et al. Safety and effectiveness of the Invatec Mo.Ma proximal cerebral protection device during carotid artery stenting: results from the ARMOUR pivotal trial. Catheter Cardiovasc Interv. 2010;76:1–8.
28. Clair DG, Hopkins LN, Mehta M, et al. Neuroprotection during carotid artery stenting using the gore flow reversal system: 30-day outcomes in the empire clinical study. Catheter Cardiovasc Interv. 2011;77:420–429.
29. Cassese S, Ndrepepa G, King L, et al. Proximal occlusion versus distal filter for cerebral protection during carotid artery stenting: a meta-analysis of magnetic resonance imaging studies. Eur Heart J. 2014;35(suppl 1):179.
30. de Castro-Afonso LH, Abud LG, Rolo JG, et al. Flow reversal versus filter protection a pilot carotid artery stenting randomized trial. Circ Cardiovasc Interv. 2013;6:552–559.
31. Mokin M, Dumont TM, Chi JM, et al. Proximal versus distal protection during carotid artery stenting: analysis of the two treatment approaches and associated clinical outcomes. World Neurosurg. 2014;81:543–548.
32. Stabile E, Sannino A, Schiattarella GG, et al. Cerebral embolic lesions detected with diffusion-weighted magnetic resonance imaging following carotid artery stenting a meta-analysis of 8 studies comparing filter cerebral protection and proximal balloon occlusion. JACC Cardiovasc Interv. 2014;7:1177–1183.
33. Paraskevas KI, Beard JD, Veith FJ. Carotid artery stenting: it’s all about appropriate patient selection and keeping to the indications. Expert Rev Cardiovasc Ther. 2014;12:783–786.
34. Brewster LP, Beaulieu R, Corriere MA, et al. Carotid revascularization outcomes comparing distal filters, flow reversal, and endarterectomy. J Vasc Surg. 2011;54:1000–1005.
35. Skjelland M, Krohg-Sorensen K, Tennoe B, et al. Cerebral microemboli and brain injury during carotid artery endarterectomy and stenting. Stroke. 2009;40:230–234.
Cite article
Cite article
Cite article
OR
Download to reference manager
If you have citation software installed, you can download article citation data to the citation manager of your choice
Information, rights and permissions
Information
Published In
Article first published online: January 21, 2016
Issue published: April 2016
Keywords
PubMed: 26794908
Authors
Metrics and citations
Metrics
Journals metrics
This article was published in Journal of Endovascular Therapy.
VIEW ALL JOURNAL METRICSArticle usage*
Total views and downloads: 367
*Article usage tracking started in December 2016
Articles citing this one
Receive email alerts when this article is cited
Web of Science: 40 view articles Opens in new tab
Crossref: 46
-
Evaluation of Robotic-Assisted Carotid Artery Stenting in a Virtual Mo...
-
The intracranial effects of flow reversal during transcarotid artery r...
-
Trans-Carotid Artery Revascularization Versus Carotid Endarterectomy i...
-
Trans-distal radial artery carotid revascularization with forearm flow...
-
Outcomes of transcarotid artery revascularization: A systematic review
-
TransCarotid Revascularization With Dynamic Flow Reversal Versus Carot...
-
Balloon dilation strategy does not affect outcomes for transcarotid ar...
-
Performance of Carotid Revascularization Procedures as Modified by Sex
-
Use of transcarotid artery revascularization for mechanical thrombecto...
-
Management of atherosclerotic extracranial carotid artery stenosis
-
TCD Monitoring During Carotid Artery Stenting
-
The Efficacy of Transcarotid Artery Revascularization With Flow Revers...
-
Comparing Manual and Robotic-Assisted Carotid Artery Stenting Using Mo...
-
Preliminary Experience With Transcranial Doppler Monitoring in Patient...
-
Transcervical carotid artery revascularization: A systematic review an...
-
European Stroke Organisation guideline on endarterectomy and stenting ...
-
Editor's Choice – Early and Late Outcomes after Transcarotid Revascula...
-
Effects of timing on in-hospital and one-year outcomes after transcaro...
-
Safety and efficacy of transcarotid artery revascularisation versus ca...
-
TCD Monitoring During Carotid Artery Stenting
-
Use of Transcarotid Artery Revascularization to Treat Symptomatic Caro...
-
A Systematic Review and Meta-Analysis of Transcarotid Artery Revascula...
-
An updated systematic review and meta-analysis of results of transcerv...
-
A systematic review and meta-analysis of carotid artery stenting using...
-
Critical Appraisal on the Quality of Reporting on Safety and Efficacy ...
-
WIRION™ Embolic Protection System for Carotid Artery Stenting and Lowe...
-
Risk factors associated with microembolization after carotid intervent...
-
Transcarotid Artery Revascularization as a New Modality of Treatment f...
-
Carotid Artery Stenting in Asymptomatic Carotid Artery Stenosis
-
Current role of transcervical carotid artery stenting with flow revers...
-
Secular Trends in Procedural Stroke or Death Risks of Stenting Versus ...
-
Recent advances in the treatment of carotid artery disease
-
Direct Transcervical Access vs the Transfemoral Approach for Carotid A...
-
Transfemoral vs Transcervical Carotid Artery Stenting
-
Age but not sex is associated with higher risk of in-hospital stroke o...
-
Carotid Artery Stenting Without Embolic Protection Device: A Single-Ce...
-
Proximal embolic protection versus distal filter protection versus com...
-
External Validation of Randomized Trial Outcomes Following Carotid Int...
-
Transcervical Carotid Stent Placement in the Setting of a Hostile Neck...
-
Preoperative cervical carotid artery contrast-enhanced ultrasound find...
-
History of Proximal Carotid Protection and Flow Reversal
-
Transcarotid Artery Revascularization With Flow Reversal...
-
Commentary: Carotid Artery Revascularization for Stroke Prevention...
-
Transcervical access, reversal of flow and mesh-covered stents: New op...
-
Techniques and innovations to improve carotid artery stenting outcomes
-
Commentary: Transcervical Carotid Artery Stenting (CAS) With Flow Reve...
Figures and tables
Figures & Media
Tables
View Options
Get access
Access options
If you have access to journal content via a personal subscription, university, library, employer or society, select from the options below:
loading institutional access options
ISEVS members can access this journal content using society membership credentials.
ISEVS members can access this journal content using society membership credentials.
Alternatively, view purchase options below:
Purchase 24 hour online access to view and download content.
Access journal content via a DeepDyve subscription or find out more about this option.
