Is Unprotected Carotid Stenting Safe?

Abstract

Background and Purpose: So far, there is no proof that protection systems reduce the risk of cerebral embolism in patients undergoing stent-assisted angioplasty of the carotid artery. However, there is increased pressure on interventionalists to use protection devices, arguing that the use of protection devices is mandatory for a safe performance of the procedure. In order to answer this question, we prospectively evaluated all carotid stenting procedures performed in our institution. We did not use protection devices at all. Methods: Between November 2001 and March 2006 we treated 56 patients with 59 stenoses. 42 out of 59 stenoses were neurologically symptomatic (71%). In all patients the indication of therapy was established by interdisciplinary discussion. Only stenoses above 70% (NASCET) were treated, provided there were contra-indications against surgery. We did not use any protection device. Preprocedural medication was ASS, Clopidogrel and Heparin. Pre- and post-interventional diffusion-weighted MRI and independent neurological examination were done. Results: In all 59 procedures a Carotid Wallstent® was implanted successfully without significant residual stenosis. There were no neurological complications. Diffusion-weighted MRI 24 hours after the procedure showed isolated small signal increases in six out of 59 procedures (10.2%). Despite anticoagulation with ASS, Clopidogrel and Heparin there were no local complications owing to a vessel closure system. Conclusion: Carotid stenting in our patient sample with our method does not require protection systems against cerebral embolism. In our interdisciplinary selected patient group which included only patients with risks higher than the average, there were no complications. In our opinion peri-interventional anticoagulation is more important than using protection systems which have their intrinsic complication rate.