Triple Balloon Protection Technique Using the Mo.Ma Ultra with the Carotid GuardWire for Carotid Stenting: Technical Note

Treatment Results of Carotid Artery Stenting with an Open-Cell Stent: Analysis of 734 Consecutive Cases at a Single Center

OBJECTIVE

In carotid artery stenting (CAS) for internal carotid artery stenosis, the stent is often selected according to the plaque properties and arterial tortuosity. In our institute, an open-cell stent is used as the first-line stent regardless of the characteristics of the lesion. This study was performed to examine the outcome of CAS with an open-cell stent as the real-world results.

METHODS

In total, 811 CAS procedures using open-cell stents were performed for internal carotid artery stenosis from April 2002 to December 2019. Of these patients, we excluded those with hyperacute conditions for which CAS was performed within 3 days of onset, those in whom acute mechanical thrombectomy was performed simultaneously with CAS, and those with stenosis due to arterial dissection. Thus, 734 patients were retrospectively analyzed. Perioperative and long-term outcomes and risk factors for perioperative infarction were investigated.

RESULTS

The periprocedural stroke rate and mortality rate were 3.7% (27/734) and 0.4% (3/734), respectively. Low-echoic plaque was a significant risk factor for periprocedural stroke in both univariate (P < 0.03) and multivariate (odds ratio, 2.69; 95% confidence interval, 1.14-6.66; P = 0.02) analyses. Cerebral infarction and high grade restenosis were observed in 15 (2.0%) and 17 (2.3%) patients during a median 50-month follow-up.

CONCLUSIONS

CAS with open-cell stents showed good results in terms of both the postoperative stroke incidence and long-term severe restenosis rate. However, low-echoic plaque was a risk factor for perioperative stroke incidence, which should be considered when deciding on the indication for CAS with an open-cell stent.

Carotid Artery Stenting for Symptomatic Internal Carotid Artery Stenosis Associated with Moyamoya Disease

BACKGROUND

Surgical intervention in a case of internal carotid artery stenosis with moyamoya vessels has not been well described. We present a case with detailed description of the surgical procedure and perioperative management.

CASE DESCRIPTION

A 58-year-old man with symptomatic internal carotid artery stenosis had concurrent moyamoya vessels intracranially. He had motor weakness and numbness in the left upper extremity. Magnetic resonance imaging showed an ischemic lesion in the right frontal lobe and right chronic subdural hematoma. On day 18 after surgery for subdural hematoma, carotid artery stenting was performed under proximal balloon protection and distal filter protection. After carotid artery stenting, systolic blood pressure was maintained at <120 mm Hg. Hyperperfusion syndrome or hemorrhagic complication did not occur. The patient was discharged without any neurologic deficits.

CONCLUSIONS

In our patient with internal carotid artery stenosis with moyamoya vessels, strict control of blood pressure likely contributed to prevention of hyperperfusion syndrome or hemorrhagic complications.

Retinal artery occlusion during carotid artery stenting with distal embolic protection device

Retinal artery occlusion associated with carotid artery stenosis is well known. Although it can also occur at the time of carotid artery stenting, retinal artery occlusion via the collateral circulation of the external carotid artery is rare. We encountered two cases of retinal artery occlusion that were thought to be caused by an embolus from the external carotid artery during carotid artery stenting with a distal embolic protection device for the internal carotid artery. A 71-year-old man presented with central retinal artery occlusion after carotid artery stenting using the Carotid Guardwire PS and a 77-year-old man presented with branch retinal artery occlusion after carotid artery stenting using the FilterWire EZ. Because additional new cerebral ischaemic lesions were not detected in either case by postoperative diffusion-weighted magnetic resonance imaging, it was highly likely that the debris that caused retinal artery occlusion passed through not the internal carotid artery but collaterals to retinal arteries from the external carotid artery, which was not protected by a distal embolic protection device. It is suggested that a distal protection device for the internal carotid artery alone cannot prevent retinal artery embolisation during carotid artery stenting and protection of the external carotid artery is important to avoid retinal artery occlusion.

Effectiveness of the Combined Use of Distal Filter Protection Device and Mo.Ma Ultra: Technical Note

BACKGROUND

Although Mo.Ma Ultra is an embolic protection device for interrupting the anterograde blood flow to the internal carotid artery, incomplete blood stagnation is often observed. We report the effectiveness of the combined use of a distal filter protection device and Mo.Ma Ultra (Medtronic, Minneapolis, MN).

MATERIALS AND METHODS

Our case series comprises 10 consecutive patients (11 carotid arteries) who underwent carotid artery stenting (CAS) using Mo.Ma Ultra and FilterWire EZ (Boston Scientific, Natick, MA).

RESULTS

The superior thyroid artery originated from the proximal side of the bifurcation of the common carotid artery, except for 1 artery. Although complete blood stagnation was observed in 6 arteries, filter debris was detected in 3 of these 6 arteries. Positive postoperative findings on diffusion-weighted magnetic resonance imaging were observed in 3 cases (3 arteries). Only 1 patient had transient neurological deficits.

CONCLUSION

The combined use of a distal filter protection device and Mo.Ma Ultra could provide a more reliable embolic protection in CAS.

Double balloon protection during carotid artery stenting for vulnerable carotid stenosis reduces the incidence of new brain lesions

BACKGROUND

The use of distal filter protection alone is associated with a high risk of ischemic complications when vulnerable carotid stenosis is treated by carotid artery stenting (CAS). Double balloon protection, a combination of distal balloon protection and proximal balloon occlusion, can be utilized. We assessed the outcome and complications of the double balloon protection method for vulnerable carotid stenosis.

METHODS

Among 130 patients who underwent CAS from 2009 to 2014, we enrolled the following patients: those whose target lesion was vulnerable as evaluated by MRI, i.e., a signal ratio of plaque to posterior cervical muscle on T1-weighted images before CAS of ≥1.5, and those who underwent diffusion-weighted imaging (DWI) studies within 48 h after the procedure. Ninety patients were enrolled. We investigated DWI findings of the double balloon protection group compared with those of the simple distal balloon protection and distal filter protection groups.

RESULTS

Sixty-four patients (71 %) underwent double balloon protection, 15 patients (17 %) simple distal balloon protection, and 11 patients (12 %) distal filter protection. Symptomatic embolic complications and new lesions on DWI after CAS were significantly less common in patients undergoing double balloon protection compared to distal balloon protection or distal filter protection (0 % vs. 20 %, 9 %, P < 0.01, and 30 % vs. 67 %, 82 %, P < 0.01, respectively). Logistic regression analysis also identified the odds ratio of double balloon protection for new lesions on DWI after CAS of 0.23 (95 % confidence interval: 0.07-0.70, P < 0.01) compared to simple distal protections.

CONCLUSIONS

In the patients who underwent CAS for vulnerable carotid stenosis, double balloon protection was an independent significant factor associated with a reduction in the risk of new lesions on DWI after the procedure compared to conventional distal protections.