The Role of Embolic Protection in Carotid Stenting Progress in Cardiovascular Diseases (PCVD)

Long-term cognitive and multimodal imaging outcomes after carotid artery stenting vs intensive medication alone for severe asymptomatic carotid stenosis

BACKGROUND

Severe carotid stenosis is associated with cognitive impairment, which may be attributed to asymptomatic microembolism and/or chronic hypoperfusion. We aim to evaluate the long-term cognitive and brain connectivity outcomes of carotid artery stenting (CAS) for asymptomatic ≥70% stenosis of the extracranial internal carotid artery (ICA).

METHODS

We conducted a non-randomized controlled study to compare intensive medical therapy alone (Med) or in combination with carotid artery stenting for the composite vascular events, neuropsychological, and multimodal magnetic resonance perfusion imaging and diffusion tensor imaging outcomes.

RESULTS

Sixty-nine patients were followed for a mean of 2.3 years (31 Med, 38 CAS) and 11 patients had composite vascular events of all-cause death, ischemic stroke, or myocardial infarction (6 Med vs 5 CAS). Forty-six asymptomatic subjects completed neuropsychological and multimodality imaging follow-ups (23 Med, 23 CAS). Compared to the Med group, the CAS group had a modest improvement of 12-item delayed verbal memory (8.9 ± 2.4 to 9.8 ± 2.7 vs 9.0 ± 2.1 to 8.9 ± 2.3, p = 0.04), but not in global cognition, attention or executive function, which was associated with increased structural connectivity of fractional anisotropy at the ipsilateral deep white matter. Importantly, the memory improvement was correlated with the perfusion increment at the ipsilateral middle cerebral artery territory.

CONCLUSION

For asymptomatic extracranial carotid steno-occlusion, successful carotid revascularization in addition to intensive medical treatment may potentially benefit cognitive reserve and connectivity strength which are partly attributed to restoration of non-critical hypoperfusion.

Successful Retrieval of the Distal Anti-embolic Device after Carotid Stenting Using the Balloon Bridge Technique

Background

During carotid artery stenting (CAS), retrieval of the distal umbrella portion of the anti-embolic device (AED) could be difficult. Herein, we report a case of left CAS managed with balloon angioplasty and stent placement with successful retrieval of the umbrella portion of the AED using the balloon bridge technique after failure of retrieval with the standard technique.

Case Presentation

After successful revascularization of the asymptomatic severe carotid bulb stenosis in a 62-year-old woman, we could not pass the re-sheathing catheter over the deployed stent because of the ledge effect between the guidewire of the AED and the stent mesh. However, using the balloon bridge technique, which helped minimize the ledge effect, we could advance the guiding catheter beyond the stented segment over the partially inflated balloon. The umbrella portion of the AED could be easily retrieved through the guiding catheter without complications.

Conclusion

During CAS, the balloon bridge technique could be used to retrieve the AED after failure of retrieval with the standard techniques.

Successful Endovascular Bailout Strategy for Retained Accunet Embolic Protection Device During Vertebral Artery Stenting

Introduction: Vertebral artery stenosis can lead to posterior circulation TIAs and stroke. Stenting is often performed to treat symptomatic vertebral artery stenosis. As with carotid stenting, embolic protection devices (EPD) are increasingly used when stenting a vertebral artery stenosis. In general, EPDs may rarely become detached or retained in the circulation during stent revascularization. We discuss a 77-year-old male with a history of cerebral atherosclerosis and prior left occipital lobe and right insular infarcts who presented with increasing left sided weakness and was found to have severe stenosis of the proximal left vertebral artery. We report the only known case and successful endovascular bailout for an irretrievable EPD occurring during vertebral artery stenting.

Methods: Systematic reviews of the medical literature were performed using PubMed and multiple combinations of keywords to search for irretrievable EPDs in either the carotid or vertebral arteries. The bibliographies of the results were used to identify additional publications until this process was exhausted.

Results: No prior reports were found for retained or detached vertebral artery EPD. A total of six cases were found where an EPD was lost in the carotid circulation. In three of the cases, a carotid arteriotomy was required to retrieve the EPD. In two other cases, diagnostic catheters were used to retrieve the EPD. In our case, an EverFlex Biliary Stent was used to flatten the irretrievable EPD into the vertebral artery wall while preserving robust vertebral artery perfusion. 21-month clinical and 16-month imaging follow-up demonstrated durable vertebral artery patency and no ischemic symptoms.

Conclusion: Successful bailout strategy for a retained vertebral artery EPD during stenting may be achieved with a self-expanding stent. The resultant revascularization remained durable and without clinical sequelae.