Cervical carotid revascularization: the role of angioplasty with stenting

Are distal protection devices 'protective' during carotid angioplasty and stenting?

BACKGROUND AND PURPOSE

To evaluate the periprocedural outcome after carotid artery stenting with embolic brain protection (EBP+) versus without embolic brain protection (EBP-).

METHODS

We retrospectively reviewed data from a prospective nonrandomized database of 357 patients who underwent carotid artery stenting in the neuroradiology division of our institution from 1999 to 2009. One hundred five patients underwent angioplasty and stenting without distal protection, whereas 252 were treated with distal protection. Patients were analyzed according to their EBP status (+ or -) for the primary end points of perioperative stroke, death, or myocardial infarction.

RESULTS

Unprotected stenting was mostly performed in the early years of this study and this is reflected in significant baseline differences between the two groups. In our earlier experience, carotid artery stenting was used in patients with more significant comorbidities. Diabetes mellitus (P=0.04), previous coronary artery disease (P=0.02) and myocardial infarction (P=0.04), and symptomatic lesion (P=0.01) were significantly more common in the EBP- cohort. Despite these baseline differences, there were no significant differences in the primary end points (2% in the EBP+ group and 4.8% in the EBP-, P=0.15). The incidence of ipsilateral stroke in the EBP- and in the EBP+ group was 3.8% versus 0.8%, respectively (P=0.6). There were 2 perioperative deaths (1 in each group) and 4 myocardial infarctions (3 in the EBP+ arm and 1 in the EBP- arm, all non-Q infarcts; P=nonsignificant).

CONCLUSIONS

In accordance with recent literature, this series cast doubts as to the real effectiveness of distal embolic protection devices in reducing periprocedural complications.

Hemorrhagic Complications after Endovascular Therapy for Atherosclerotic Intracranial Arterial Stenoses

OBJECTIVE:

Hemorrhagic complications were analyzed in 106 procedures of 99 patients treated with percutaneous transluminal angioplasty (PTA) or stenting for intracranial arterial stenoses.

METHODS:

Ninety-nine patients with intracranial arterial stenosis were treated with PTA or stenting 106 times from January 1995 to December 2003. Fifty-seven patients had intracranial internal carotid artery stenosis, 23 had middle cerebral artery stenosis, and 19 had vertebrobasilar stenosis. Evaluation of hemodynamic compromise via single-photon emission computed tomography was performed 50 times for 50 patients before the treatment.

RESULTS:

Four hemorrhagic complications occurred in 106 procedures. Two of these cases involved intracerebral hemorrhage after PTA or stenting in the treated vascular territory 30 minutes and 16 hours after the treatment, respectively. One case showed subarachnoid hemorrhage, which appeared 6 hours after treatment. Hemodynamic compromise was found on single-photon emission computed tomography in these three cases. The last case with a hemorrhagic complication was a hemorrhagic infarction after recanalization of stent thrombosis, which appeared 3 days after stenting. Hyperperfusion syndrome was strongly suggested as the cause of hemorrhage in the two cases associated with intracerebral hemorrhage.

CONCLUSION:

The rate of hemorrhagic complication directly related to the procedure of PTA or stenting was 3%, and hyperperfusion syndrome was suggested as the cause of hemorrhage in two cases (2%), from the perspective of clinical characteristics and single-photon emission computed tomographic findings.