Proximal Protection Research Articles

Lower Endoscopy and Prevention of Colon Cancer

Lower Endoscopy and Prevention of Colon Cancer

Asymptomatic Carotid Stenosis and Cognitive Improvement using Transcervical Stenting with Protective Flow Reversal Technique

The relationship between carotid artery stenosis and cognitive function in individuals without a history of stroke is not clear. The possible pathomechanisms of cognitive impairment include silent embolization and hypoperfusion. In this study the aim was to assess cognitive changes after transcervical carotid artery stenting with proximal cerebral protection by flow reversal in patients with asymptomatic carotid stenosis, a novel technique that has been proved to decrease the number intraoperative emboli. 25 consecutive patients were assessed, of which 22 were men (88%) mean age of 74 years with severe asymptomatic carotid stenosis who underwent revascularization by carotid artery stenting (CAS) with flow reversal. Patients were evaluated 1 day before and 6 months after the procedure using a standardized neuropsychological battery. Test scores were adjusted according to age, sex, education level and were standardized (0-100). The mean of all the cognitive function scores yielded the global cognitive score (GCS). There were no neurological complications during the procedure or during hospitalization in any patient. No deaths or cardiac complications occurred in any patient. The pre-procedure neuropsychological study showed cognitive impairment in: information processing speed in 15 patients (62.5%), visuospatial function in 14 (56.0%), memory in 18 (72.0%), executive functions in 14 (56.0%), language in three (12.0%), attention in 10 (40.0%), and global cognitive performance in eight (32.0%). Comparison of these scores with those obtained 6-month post-procedure showed significant improvement in GCS in all patients (p = .002), with a particularly marked gain in information processing speed (p = .018). Although significant improvement was not found for the remaining cognitive functions assessed, some gain was documented, and there was no deterioration. Revascularization by transcervical CAS with flow reversal for cerebral protection results in improved neurocognitive performance in asymptomatic elderly patients with severe carotid artery stenosis.

TCTAP A-048 A Downsizing of Carotid Artery Stenting with Proximal Protection Method Using “Sheathless OPTIMO Guiding Catheter System”

Distal embolism inducing stroke in the course of CAS is one of the most terrible periprocedural complications. Thanks to the innovation of distal protection devices including balloons and filters, the complication rate of stroke has had a downward tendency. There're some reports saying PPM is more

PROXIMAL EMBOLIC PROTECTION DECREASES CEREBRAL MICROEMBOLIZATION COMPARED TO DISTAL PROTECTION FOR CAROTID STENTING: A META-ANALYSIS

Embolic protection devices have become standard of care during carotid artery stenting (CAS) to reduce periprocedural stroke risk. Distal Protection Devices (DPD) were the first and are the most commonly used devices. Proximal protection devices (PPD) avoid lesion crossing and thus are potentially

Carotid Artery Stenting in Patients With Left ICA Stenosis and Bovine Aortic Arch: A Single-Center Experience in 60 Consecutive Patients Treated Via the Right Radial or Brachial Approach

To assess the safety and efficacy of carotid artery stenting (CAS) of the left internal carotid artery (LICA) from a right radial/brachial approach in patients with bovine aortic arch. Among 505 consecutive CAS patients treated at our facility between June 2007 and December 2012, 60 (11.9%) patients (44 men; mean age 73±9 years) with LICA stenosis and bovine arch were treated from a right radial (n=32) or brachial (n=28) approach. Three quarters of the patients had characteristics qualifying them at high surgical risk; 52 were asymptomatic. The types of cerebral protection (a distal filter or proximal MO.MA system), stent, and technique were at the operation's discretion. The radial/brachial approach was successful in 59 (98.3%) of 60 procedures; 1 case was converted to a femoral approach. Proximal protection was used in 15 cases (11 brachial, 4 radial) with severe, soft plaques, although the MO.MA system proved too short in a tall patient having a radial approach and a filter was used. Clinical success with no adverse events was 96.7% owing to 1 retinal embolism and 1 minor stroke. Vascular complications occurred in 2 (3.3%) brachial group patients. No major bleeding was encountered. Over a mean follow-up of 18.7±17.5 months, midterm event-free survival was 93%. No target vessel revascularization was necessary. CAS via a right radial or brachial approach is safe and effective in patients with LICA stenosis and types 1 or 2 bovine arch.

Endovascular Advances for Extracranial Carotid Stenosis

Carotid artery stenting has become a viable alternative to carotid endarterectomy in the management of carotid stenosis. Over the past 20 years, many trials have attempted to compare both treatment modalities and establish the indications for each one, depending on clinical and anatomic features presented by patients. Concurrently, carotid stenting techniques and devices have evolved and made endovascular management of carotid stenosis safe and effective. Among the most important innovations are devices for distal and proximal embolic protection and new stent designs. This paper reviews these advances in the endovascular management of carotid artery stenosis within the context of the historical background.

慢性期内頚動脈完全閉塞に対する脳血管内治療

EC-IC bypass based on the inclusion criteria of Japanese EC-IC Bypass Trial (JET study) is recommended for chronic total occlusion (CTO) of the internal carotid artery (ICA). But patients who do not meet the inclusion criteria of the JET study are also entitled to the best possible medical treatment. Recently several authors have reported the successful endovascular recanalization of CTO of the ICA. We report 10 cases of symptomatic CTO of the ICA that did not meet the inclusion criteria of the JET study that were treated by endovascular recanalization. Cerebral angiogram showed complete occlusion of the ICA and opacification of the cavernous segment of ICA or the more proximal portion of the ICA via collateral channels. Xenon CT (Xe-CT) showed hemodynamic compromise in all cases. The endovascular procedure was performed by proximal balloon protection of the common carotid arery and the external carotid artery via transfemoral route under local anesthesia. The occlusion of the ICA was recanalized successfully in all cases. Carotid artery stenting (CAS) was performed in eight cases identified as occlusion at the cervical ICA, and percutaneous transluminal angioplasty (PTA) with stenting using coronary stents was performed in two cases identified as occlusion at the cavernous or petrous ICA. Neither new ischemic symptoms nor hyperperfusion syndrome appeared after treatment. Endovascular recanalization of symptomatic CTO of the ICA can be considered as an alternative treatment for patients who do not meet the inclusion criteria of the JET study.

Randomized Comparison of Distal and Proximal Cerebral Protection During Carotid Artery Stenting

This study sought to randomly compare cerebral protection with ANGIOGUARD (Cordis Corporation, Bridgewater, New Jersey) with Mo.Ma (Invatec/Medtronic Vascular Inc, Santa Rosa, California) during carotid artery stenting (CAS), using diffusion-weighted magnetic resonance imaging (DW-MRI) to detect new ischemic cerebral lesions. The number, size, and location of lesions were analyzed. The choice of the type of cerebral protection during CAS is controversial. From July 2008 to July 2011, 60 patients undergoing CAS were randomized to ANGIOGUARD or Mo.Ma, distributed by chance, 30 patients for each group. All patients underwent DW-MRI before and after CAS. An independent neuroradiologist blinded to the cerebral protection used analyzed the images. Univariate and multivariate logistic models were fitted to analyze new ischemic lesions. Alternatively, a propensity score approach was used to reduce the bias due to differences between the groups. For the number of lesions, we used Poisson regression models. New ischemic lesions seen on DW-MRI were present in 63.3% of the ANGIOGUARD group versus 66.7% of the Mo.Ma cohort (p= 0.787). The number of ischemic cerebral lesions per patient, when present, was significantly lower in the Mo.Ma group (a median of 6 lesions per patient vs. a median of 10 in the ANGIOGUARD, p < 0.001). Most lesions were small (<0.5 mm) and localized in the ipsilateral territory. One patient in the ANGIOGUARD group had a minor stroke during CAS (1.66%). New ischemic lesions seen on DW-MRI were present in both groups in >60%, but the number of lesions per patient was greater in the ANGIOGUARD group. No death or disabling stroke occurred during at least 1 year of follow-up in both cohorts.

Carotid artery stenting: Clinical and procedural implications for near-occlusion stenosis

Introduction and objectivesThe advisability of implanting a stent in carotid near-occlusion stenosis is a controversial topic. We have assessed procedural and clinical implications of stent implantation for carotid artery disease with near occlusion. MethodsWe included 205 patients who underwent carotid artery revascularisation with a stent. The group of patients with near-occlusion stenosis (n=54) was compared to the rest of the population (n=151). ResultsNo differences were found between groups for age, sex, and the percentage of symptomatic patients (three-quarters of the population). Carotid stent revascularisation for near-occlusion stenosis presented a high procedural success rate (96%) similar to that of revascularisation processes for other lesions (98%). Stenting in cases of near-occlusion stenosis required increased use of proximal protection (54% vs. 20.5%, P<0.001) and predilation (33% vs. 17%, P=0.01). The process to repair near-occlusion stenosis causes increased detachment of plaque, as shown by higher percentages of macroscopic plaque captured by protection devices (18.5% vs. 7%, P=0.01) and of perioperative ischaemic brain lesions (47% vs 31%, P=0.07). At 30 days of follow-up, the tendency towards adverse neurological events (death, major and minor stroke) was higher in the near-occlusion group (9.2% vs. 3.2%, P=0.08). ConclusionsStent revascularisation for near-occlusion carotid stenosis has a high procedural success rate; however, its higher plaque load was responsible for the increased rate of ischaemic brain lesions and adverse neurovascular events at 30 days post-procedure.

Carotid Artery Back Pressure and Cerebral Intolerance During the Occlusion in Carotid Stenting with the Mo.Ma Proximal Embolic Protection Device

OP-173 The Mo.Ma proximal embolic protection system provide neuroprotection during all phases of the carotid artery stenting (CAS) procedure. However, cerebral intolerance is not an infrequent occurrence with this approach. In most of the cases, intolerance is a benign phenomenon which resolves

TCT-506 Predictors Of Carotid Clamping Intolerance During Carotid Artery Stenting With Proximal Embolic Protection Device. Results From An Italian Registry.

TCT-506 Predictors Of Carotid Clamping Intolerance During Carotid Artery Stenting With Proximal Embolic Protection Device. Results From An Italian Registry.

Erratum to: Comparison Between Proximal Versus Distal Protection Devices in 287 Cases of Carotid Revascularization Using Angioplasty and Stenting: Periprocedure Complications, Morbidity, and Mortality

Erratum to: Comparison Between Proximal Versus Distal Protection Devices in 287 Cases of Carotid Revascularization Using Angioplasty and Stenting: Periprocedure Complications, Morbidity, and Mortality

Comparison Between Proximal Versus Distal Protection Devices in 287 Cases of Carotid Revascularization Using Angioplasty and Stenting: Periprocedure Complications, Morbidity, and Mortality

Embolic protection devices may decrease periprocedural thromboembolic complications during carotid angioplasty and stenting (CAS). When using proximal-protection devices (PPDs), protection starts before crossing the lesion. However, in the medical literature, its use is scarcely reported compared with that of distal-protection filters (DPDs). The objective of this study was to compare periprocedure complications, morbidity, and mortality among 287 consecutive cases of CAS performed with PPDs or DPDs. This was a retrospective analysis of 287 patients treated with CAS at our hospital between January 2006 and March 2012. Periprocedure complications, morbidity, and mortality at 30 days, including ischemic stroke or transient ischemic attack, reperfusion syndrome, myocardial infarction (MI), and death, were globally registered, and the results in PPD and DPD groups were compared. Two hundred eight patients were treated with DPD and 79 with PPD; 80.8 % were symptomatic. CAS procedures performed with PPD presented a statistically significant greater grade of stenosis than those with DPD (82.5 vs. 74.5 %, p < 0.001). Death rates were 1.9 and 1.3 %; stroke rates were 4.3 and 3.8 %; MI rates were 1.4 and 1.3 %; and total morbidity and mortality rates were 6.2 and 5 % (DPD and PPD groups, respectively); all differences were nonstatistically significant. No statistical difference was found between symptomatic and asymptomatic patients. Carotid angioplasty and stenting is a safe procedure to treat carotid disease in our patients. PPDs are not always associated with a greater risk of periprocedure complications, morbidity, and mortality than DPDs despite the greater grade of carotid stenosis in the PPD group. This observation may be of interest in the design of future studies with CAS.

Proximal embolic protection devices for high risk lesions/patients in "TARGET-CAS" registry of 1717 consecutive carotid artery stenting procedures

Proximal embolic protection devices for high risk lesions/patients in "TARGET-CAS" registry of 1717 consecutive carotid artery stenting procedures

Carotid artery stenting using the proximal or dual protection method for near occlusion of the cervical internal carotid artery

The treatment for patients with near occlusion of the cervical internal carotid artery (ICA) is controversial. The aim of this study was to examine the results of carotid artery stenting (CAS) as a surgical treatment for ICA near occlusion. Between April 2008 and September 2012, 14 patients (all men; mean age, 75.4 years) with ICA near occlusion were treated with CAS. This represents 5.2% of a total of 267 patients treated with CAS during the study period. All patients were treated with CAS using an embolic protection device. The proximal balloon protection method was performed in five patients, and the dual protection method using a proximal balloon and distal filter protection was used in nine patients. We examined the change of stenotic lesion, hyperintensity spot in diffusion-weighted imaging (DWI), and perioperative complications after CAS. All near occlusions were successfully dilated. Among 2 of 14 patients, DWI showed 1 and 4 hyperintensity spots. Transient and persistent complications, including neurological deficits, did not occur in any patients. In this small number of cases, CAS using the proximal or dual embolic protection method seems to be a safe and beneficial treatment for ICA near occlusion.

Proteção cerebral em pacientes idosos durante implante de stent carotídeo

BACKGROUND: The type of cerebral protection used during carotid stenting in the elderly is controversial. Our objective was to evaluate the results of proximal and distal cerebral embolic protection devices (EPDs), in patients > 70 years through diffusion-weighted magnetic resonance imaging (DW-MRI). METHODS: Between 2008 and 2011, 60 patients with indication for carotid stenting were randomized to EPD with Mo.Ma® or Angioguard®, of which 26 patients were > 70 years of age. Results of DW-MRI performed before and 48 hours after the procedure were evaluated by an independent neurologist blinded to the type of EPD used. New ischemic lesions, their localization and size were analyzed. RESULTS: New cerebral ischemic lesions were found in 8/12 (66.7%) patients in the Mo.Ma® group and 12/14 (85.7%) patients in the Angioguard® group (P = 0.37). The vast majority of the lesions (> 90%) were ipsilateral to the treated artery in both groups and the size of the lesions was < 0.5 cm in most cases. The number of lesions per patient was lower with the Mo.Ma® device (median [variation]: 3 [1 to 8] lesions vs 15 [2 to 76] lesions; P < 0.001). All of the patients with more than 40 lesions were in the Angioguard® group. CONCLUSIONS: Despite the use of EPDs (proximal or distal), new ischemic lesions were observed in both groups in elderly patients. A proportionately larger number of patients with Angioguard® had new ischemic lesions when compared to those with Mo.Ma®. The Mo.Ma® device seems to decrease the number of lesions per patient.

Revascularización carotídea con stent: implicaciones clínicas y para el procedimiento de la presencia de una lesión suboclusiva

Introduction and objectivesThe advisability of implanting a stent in carotid near-occlusion stenosis is a controversial topic. We have assessed procedural and clinical implications of stent implantation for carotid artery disease with near occlusion. MethodsWe included 205 patients who underwent carotid artery revascularisation with a stent. The group of patients with near-occlusion stenosis (n=54)was compared to the rest of the population (n=151). ResultsNo differences were found between groups for age, sex, and the percentage of symptomatic patients (three-quarters of the population). Carotid stent revascularisation for near-occlusion stenosis presented a high procedural success rate (96%) similar to that of revascularisation processes for other lesions (98%). Stenting in cases of near-occlusion stenosis required increased use of proximal protection (54% vs. 20.5%, P<.001) and predilation (33% vs. 17%, P=.01). The process to repair near-occlusion stenosis cause increased detachment of plaque, as shown by higher percentages of macroscopic plaque captured by protection devices (18.5% vs. 7%, P=.01) and of perioperative ischaemic brain lesions (47% vs 31%, P = .07). At 30 days of follow-up, the tendency toward adverse neurological events (death, major and minor stroke) was higher in the near-occlusion group (9.2% vs. 3.2%, P=.08). ConclusionsStent revascularisation for near-occlusion carotid stenosis has a high procedural success rate; however, its higher plaque load was responsible for the increased rate of ischaemic brain lesions and adverse neurovascular events at 30 days post-procedure.

Abstract WP155: The Safety And Efficacy Of Carotid Artery Stenting In A High Grade Stenosis More Than 80% Under Proximal Protection With Flow-reversal System.

Background: Different embolic protection devices in carotid artery stenting(CAS) have been developed to prevent procedural cerebral embolization. Proximal flow reverse protection has theoretically advantages from the view point of prevention of distal embolism, compared with distal protection. On the other hand, there is a disadvantage that this system is complexity. Purpose: we evaluated the safety and efficacy of proximal reverse flow protection for CAS in patients with high-grade stenosis. Methods: Distal protection has mainly been used as protection device in our institute. In case that there was high possibility of distal embolism, proximal reverse flow protection has been used. These cases treated with proximal flow reverse protection were included in this study. A total of 75 patients(71 men, mean age 71.9 years) with a high grade stenosis≧80% were treated between September 2003 and March 2012. 72% (n=54) of the patients were symptomatic.The primary endpoint was death and stroke rate at 30 days. The outcome was also compared to data from 386 patients with a high-grade stenosis who were treated under only distal protection device in the same period. Results: The procedure was technically successful in all cases. In 2 cases out of proximal reverse flow protection group, intracerebral hemorrhage was occurred. However, there was no ischemic complication. In distal protection group, the incidence of complication occurred in 11 cases (7 ischemic, 4 otheres). The stroke/death rate at 30 days was 2.6% (n=2) in proximal reverse flow protection group compared to 2.8% (n=11) in the distal protection group. There was no significant difference. However, the incidence of ischemic complication in the proximal reverse flow protection group tended to be lower than that of distal protection group. Conclusion: In selected patients with large atherosclerotic plaques, the clinical results of CAS with proximal reverse flow protection is safe and feasible. Especially, the incidence of ischemic stroke was lower than that of distal protection.

Comparison of anti-embolic protection with proximal balloon occlusion and filter devices during carotid artery stenting: clinical and procedural outcomes.

AimThe objective of this study was to compare the periprocedural and clinical outcomes after carotid artery stenting (CAS) with proximal protection devices versus with distal protection devices.Material and methodsPatients with internal carotid artery (ICA) stenosis undergoing CAS with cerebral embolic protection were randomly assigned to proximal balloon occlusion or distal filter protection. Adverse events were defined as death, major stroke, minor stroke, transient ischemic attack (TIA) and myocardial infarction (MI). Periprocedural and 30-day adverse events and ICA vasospasm rates were compared between the two embolic protection groups.ResultsEighty-eight consecutive patients were randomized: 48 patients with proximal protection (mean age 68.8 ±13.6, 66% male) and 40 patients with a distal protection device (mean age 65.4 ±12.3; 70% male). There was no significant difference in periprocedural or 30-day adverse event rates between the two groups (p > 0.05). However, there was a higher periprocedural ICA vasospasm rate in the distal filter protection group (9 patients, 23%) compared with the proximal balloon occlusion group (1 patient, 2%) (p = 0.019).ConclusionsThere was no difference between the clinical periprocedural and 30-day adverse event rates of distal filter and proximal balloon protection systems. However, distal filter protection systems showed higher rates of periprocedural ICA vasospasm.

Cerebral Protection in Elderly Patients during Carotid Stenting

The type of cerebral protection used during carotid stenting in the elderly is controversial. Our objective was to evaluate the results of proximal and distal cerebral embolic protection devices (EPDs), in patients > 70 years through diffusion-weighted magnetic resonance imaging (DW-MRI). Between 2008 and 2011, 60 patients with indication for carotid stenting were randomized to EPD with Mo.Ma® or Angioguard®, of which 26 patients were > 70 years of age. Results of DW-MRI performed before and 48 hours after the procedure were evaluated by an independent neurologist blinded to the type of EPD used. New ischemic lesions, their localization and size were analyzed. New cerebral ischemic lesions were found in 8/12 (66.7%) patients in the Mo.Ma® group and 12/14 (85.7%) patients in the Angioguard® group (P = 0.37). The vast majority of the lesions (> 90%) were ipsilateral to the treated artery in both groups and the size of the lesions was < 0.5 cm in most cases. The number of lesions per patient was lower with the Mo.Ma® device (median [variation]: 3 [1 to 8] lesions vs 15 [2 to 76] lesions; P < 0.001). All of the patients with more than 40 lesions were in the Angioguard® group. Despite the use of EPDs (proximal or distal), new ischemic lesions were observed in both groups in elderly patients. A proportionately larger number of patients with Angioguard® had new ischemic lesions when compared to those with Mo.Ma®. The Mo.Ma® device seems to decrease the number of lesions per patient. Proteção Cerebral em Pacientes Idosos durante Implante de Stent Carotídeo O tipo de proteção cerebral utilizado durante o implante de stent carotídeo é controverso em idosos. Nosso objetivo foi avaliar os resultados dos dispositivos de proteção embólica cerebral (PEC), proximal e distal, em pacientes > 70 anos de idade, por meio da ressonância magnética ponderada de difusão (RM-PD). Entre 2008 e 2011, 60 pacientes com indicação de stent carotídeo foram randomizados para PEC com Mo.Ma® ou Angioguard®, dos quais 26 tinham > 70 anos de idade. Os resultados da RMPD realizada antes e 48 horas após o procedimento foram avaliados por neurologista independente e cego para o tipo de PEC utilizado. Foram analisados o número de novos focos isquêmicos, sua localização e o tamanho. Novos focos isquêmicos cerebrais foram encontrados em 8/12 (66,7%) pacientes do grupo Mo.Ma® e em 12/14 (85,7%) pacientes do grupo Angioguard® (P = 0,37). A maioria das lesões (> 90%) era ipsilateral à artéria tratada em ambos os grupos, e o tamanho das lesões foi < 0,5 cm na maioria dos casos. O número de lesões por paciente foi menor com o dispositivo Mo.Ma® (mediana [variação]: 3 [1 a 8] lesões vs. 15 [2 a 76] lesões; P < 0,001). Todos os pacientes que tiveram mais de 40 lesões pertenciam ao grupo Angioguard®. Mesmo utilizando PEC (proximal ou distal), novas lesões isquêmicas foram observadas em ambos os grupos em pacientes idosos. Proporcionalmente maior número de pacientes com Angioguard® teve novos focos isquêmicos se comparados aos pacientes do grupo Mo.Ma®. O dispositivo de PEC Mo.Ma® parece diminuir o número de lesões por paciente.