Procedural embolic protection strategies for carotid artery stenting: current status and future prospects

INTRODUCTION

Carotid artery angioplasty and stenting (CAS) is an established procedure to treat carotid artery stenosis for either primary or secondary prevention of stroke. Randomized clinical trials have shown an increased risk of periprocedural cerebrovascular events with CAS compared with carotid endarterectomy (CEA). Several strategies have been proposed to mitigate this risk, including alternative vascular access site, proximal/distal embolic protection devices, and dual-layer stents, among others.

AREAS COVERED

This review provides a general overview of current embolic protection strategies for CAS. The phases of the procedure which can affect the early risk of stroke and how to reduce it with novel techniques and devices have been discussed.

EXPERT OPINION

Innovations in device technologies have dramatically improved the safety and efficacy of CAS. To minimize the gap with surgery, a thorough, patient-oriented approach should be pursued. Endovascular technologies and techniques should be selected on an individual basis to address unique lesion characteristics and vascular anatomies. Meticulous pre-procedural planning, both clinical and anatomical, is needed to assess the embolic risk of each procedure. Only by having an in-depth understanding of the wide range of available endovascular devices and techniques, the operator will choose the most appropriate strategy to optimize CAS results.

481 VITAMIN K ANTAGONISTS, DIRECT ORAL ANTICOAGULANTS, OR LEFT ATRIAL APPENDAGE CLOSURE FOR PATIENTS WITH NONVALVULAR ATRIAL FIBRILLATION: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Background

Percutaneous left atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative to long-term oral anticoagulation with vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC) for stroke prevention in patients with non-valvular atrial fibrillation.

Methods

We searched PubMed and Embase for randomized controlled trials (RCT) comparing 3 different strategies (DOAC vs VKA, LAAC vs VKA, LAAC vs DOAC). Treatment effects were calculated from a network meta-analysis using random-effect model with inverse-variance weighting. The ranking probability of each treatment was based on SUCRA. The primary endpoint was a composite of stroke or systemic embolism.

Results

A total of 7 RCTs and 73,106 patients were included. The risk of the primary endpoint was comparable between LAAC and oral anticoagulation (LAAC vs VKA: OR 0.87, 95% CI 0.55-1.39; LAAC vs DOAC: OR 1.00, 95% CI 0.62-1.61) while it was reduced with DOAC vs VKA (OR 0.87, 95% CI 0.77-0.98). Major bleeding was numerically lower with LAAC vs VKA (OR 0.74, 95% CI 0.48-1.16) and similar between LAAC and DOAC (OR 0.93, 95% CI 0.61-1.42). LAAC significantly reduced the risk of mortality compared with both VKA (OR 0.52, 95% CI 0.37-0.73) and DOAC (OR 0.58, 95% CI 0.42-0.82). The probability of being the best treatment for stroke or systemic embolism prevention was similar for DOAC (51%) and LAAC (48%) whereas LAAC ranked as best treatment for reducing major bleeding (64%) and mortality (100%).

Conclusions

LAAC is a safe and effective alternative to DOAC and VKA for the secondary prevention of patients with non-valvular atrial fibrillation.

Angiographic Predictors of Septal Collateral Tracking During Retrograde Percutaneous Coronary Intervention for Chronic Total Occlusion: Anatomical Analysis or Rolling the Dice?

OBJECTIVES

The aim of this study was to identify independent angiographic predictors of collateral channel (CC) tracking success, microcatheter tracking failure, and complications in chronic total occlusion (CTO) retrograde approach. We also developed a "crossability score," comparing its predictive performance with pre-existing scores.

BACKGROUND

The retrograde approach was introduced for recanalization of challenging CTOs. The passage of guidewires through CCs is a key step of the procedure. Two scoring systems have been recently developed to predict CC tracking success.

METHODS

A total of 180 patients and 297 CCs were retrospectively analyzed in an unselected retrograde CTO population.

RESULTS

Guidewire crossing was successful in 203 collaterals (68.3%). The only independent predictor of successful CC tracking was Werner score 2. Conversely, Werner score 0, severe tortuosity (>180°), acute exit angle (<90°), and length of collateral were independently associated with tracking failure. We assigned a score to each "significant" variable to create a model that showed a greater accuracy than pre-existing scores (area under the receiver-operator characteristics curve, 0.72 vs 0.65 and 0.69). Moreover, CC length was also associated with microcatheter tracking failure and complications.

CONCLUSIONS

Werner score 0, tortuosity, acute exit angle, and CC length were independently associated with CC tracking failure, whereas Werner score 2 was a predictor of crossing success. Length of CC is associated with a higher rate of microcatheter crossing failure and complications. We combined these findings into the R-ICPS score, which showed an adequate accuracy for collateral crossing prediction.

An Uncommon Case of Spontaneous Hemopericardium in a Patient Treated with Rivaroxaban

We describe a case of an 88-year-old woman with a severe bluntly ematic pericardial effusion. Radiological and laboratory examinations excluded all the most common causes of hemopericardium, and the diagnosis of spontaneous hemopericardium associated with the treatment with rivaroxaban was made. This is the first case report describing a hemopericardium in a patient treated with rivaroxaban who did not take other herbal products or drugs that may significantly increase rivaroxaban blood levels. This report emphasizes the need for the careful use of new oral anticoagulants, and the importance of taking in mind uncommon side effects. Spontaneous hemopericardium should be considered in these patients.