Проблема мікроемболії при каротидному стентуванні та її вирішення

Abstract

Objective – to reduce of frequency of microembolism in carotid stenting with optimizing the choice of anti-embolic protection and using double-layer stents. Materials and methods. In the endovascular center of the Dnipropetrovsk Regional Hospital named after I.I. Mechnikov 41 patients (24 men and 17 women, aged from 56 to 81 years, average age – 66.9 year) underwent carotid stenting with the use of Casper double-layer carotid stents (Micro- Vention) and a differentiated approach to the choice of anti-embolic protection for the last 9 months. 47 operations of carotid stenting were performed. Before carotid stenting and in the early postoperative period (1-2 days), patients underwent MRI of the brain with a DWI protocol to determine the appearance of new embolic ischemic lesions in the postoperative period. Distal anti-embolic devices were used in all cases where the risk of their use was not regarded as increased (n = 43). The proximal anti-embolic device Mo.MaUltra (Medtronic) was used in three cases with extended stenosis, «complicated» subtotal stenosis. The method of combined usage of the proximal anti-embolic device Mo.MaUltra and the distal anti-embolic device was used in a case with complicated subtotal extended carotid stenosis and temporary carotid artery occlusion intolerance. In all observations plaques in the initial segment of the internal carotid arteries had signs that increased the risk of microembolism in the postoperative period with the usage of not double-layered design carotid stents. Therefore, we used Casper double-layer stents in these cases. Results. Elimination of the carotid stenosis was achieved in 100 % of cases. After the Casper stent implantation, if there were ulcerations, angiographically, there was no contrasting under the stent in ulcerations, or prolonged stagnation in them. There were also no angiographic signs of plaque prolapse through the structure of the stent. MRI of the brain in the DWI-regime did not show any new ischemic lesions in a control study after carotid stenting (1-2 days). There was anneurological improvement in 85.4 % of cases (35 patients). The condition of other patients remained stable, without deterioration in the neurological status. The clinic of ischemic stroke did not develop in any patient for the period from 30 days to 9 months after carotid stenting. Moderate hyperperfusion syndrome developed in the postoperative period in 2 cases (4.9 %) with complete regression of symptoms in the subsequent period. Postoperative mortality was 0 %. There were no local complications at the artery puncture site. Conclusions. Analysis of the results of treatment of patients with carotid stenoses with the usage of double-layer stents and a differentiated choice of the method of anti-embolic protection showed that this approach can lead the carotid stenting technique to a new level of efficiency and safety.