Head-to-head comparison of two embolic protection devices in carotid artery stenting

Abstract

Abstract Introduction Embolic protection devices (EPD) have been developed to reduce the risk of distal embolization and have become ubiquitous in carotid interventions. There are two classes of EPD: distal filter EPD (f-EPD) and proximal EPD (p-EPD). However, the best device for carotid artery stenting (CAS) has yet to be established. Purpose We aimed to assess and compare the early prognosis between the f-EPD and p-EPD groups in patients undergoing CAS. Methods Single-center, retrospective study. Patients who underwent CAS from 2000 to 2022 were included. The composite of transient ischemic attack(TIA)/stroke and death at 24 hours and 30 days were evaluated. Statistical analysis was performed using SPSS 28.0.1.1 software. Results A total of 436 patients were included (380 and 56 patients used f-EPD and p-EPD, respectively). The population's mean age (±SD) was 71,8 (±8,2) years, 74,8% men. There was a significant prevalence of arterial hypertension (88,3%), dyslipidemia (75,9%), diabetes (33,9%), and smoking background (25,9%). Regarding baseline clinical characteristics, arterial hypertension was more prevalent in the f-EPD group, with statistical significance (91,7% vs. 78,8%; p=0,003). Concerning the indications for carotid intervention, 16,1% of patients were asymptomatic but had severe stenosis, and 39,4% had neurological symptoms. In 41,9% of patients, the procedure was accomplished before cardiac surgery (coronary artery bypass graft or valvular surgery). Regarding the first 24 hours after the procedure, the combined endpoint of TIA/stroke or death occurred in 3,4% of patients in the f-EPD group and 3,6% in the p-EPD group, with no statistically significant difference (p=1,000). The incidence of TIA/stroke was also similar in both groups (3,2% and 3,6% in the f-EPD and p-EPD groups, respectively; no statistical difference was found; p=0,694). The early mortality rate was slightly lower in the f-EPD group (0,8%) compared with the p-EPD group (1,8%), though this difference did not reach statistical significance (p=0,424). During the 30-day follow-up, the combined endpoint of TIA/stroke or death occurred in 1,6% of patients in the f-EPD group and 1,8% in the p-EPD group, with no statistically significant difference (p=1,000). The incidence of TIA/stroke was lower in the f-EPD group (1,1%) compared to the p-EPD group (1,8%), however, no statistical difference was found (p=0,499). Regarding mortality rate, the incidence in the f-EPD group was 0,5%, in contrast with no events in the p-EPD group (statistical analysis not possible to compute). Conclusion In this cohort, no significant differences were found between the distal filter and proximal embolic protection devices in the risk of TIA/stroke and death at 24 hours and 30 days after carotid artery stenting. However, conclusions should be carefully drawn since the distal filter EPD was used more often than the proximal EPD, making direct comparisons challenging.