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Carotid artery stenting under proximal balloon protection via the transbrachial approach using a balloon guiding catheter: sheathless method with 9Fr Optimo
Abstract and Figures
Objective: Proximal balloon protection (PBP) in carotid artery stenting via the transbrachial carotid artery stenting (TB-CAS) approach has not been feasible because a large-sized sheath introducer is required. We report a novel technique of TB-CAS using sheathless balloon guiding catheter navigation.Case presentation: A 76-year-old male presented with a symptomatic left internal carotid artery stenosis. Transfemoral approach was difficult because of severe arteriosclerosis obliterans. A 9Fr Optimo 90 cm was inserted into the right brachial artery over a 6Fr long dilator 108 cm by the coaxial method without sheath introducer, and it was advanced into the right subclavian artery. A long dilator was exchanged with an inner catheter and a 9Fr Optimo was navigated into the common carotid artery by using the telescoping technique. Further procedures were successfully performed by PBP using a 9Fr Optimo. The patient's postoperative course was uneventful, and follow-up head MRI did not reveal any distal embolization.Conclusion: This technique is useful in high-risk patients of distal thromboembolic complication in CAS with difficult femoral access, because it enables PBP by TB-CAS.
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... 10) It was recently suggested that the use of a balloon guiding catheter (BGC) improves the recanalization rate, 12) but they are difficult to use in dTRA. To use a BGC in the current MT through dTRA, one with a thin diameter may be used with a thin BGC and stent retriever 13) or a sheathless BGC with a wide diameter.. 14) In the former, an aspiration catheter cannot be concomitantly used when it is necessary, whereas in the latter, even though it is used sheathlessly, applicable cases are limited because the outer diameter of the BGC is large (outer diameter of a 9Fr BGC is approximately 3.0 mm 14) ) in consideration of the mean vascular diameter of the deep palmar br. Therefore, the use of a guiding catheter is limited, being the weakest point of MT through dTRA. ...
... 10) It was recently suggested that the use of a balloon guiding catheter (BGC) improves the recanalization rate, 12) but they are difficult to use in dTRA. To use a BGC in the current MT through dTRA, one with a thin diameter may be used with a thin BGC and stent retriever 13) or a sheathless BGC with a wide diameter.. 14) In the former, an aspiration catheter cannot be concomitantly used when it is necessary, whereas in the latter, even though it is used sheathlessly, applicable cases are limited because the outer diameter of the BGC is large (outer diameter of a 9Fr BGC is approximately 3.0 mm 14) ) in consideration of the mean vascular diameter of the deep palmar br. Therefore, the use of a guiding catheter is limited, being the weakest point of MT through dTRA. ...
Objective: We report a case of mechanical thrombectomy (MT) via the distal transradial approach (dTRA) and technical tips.
Case Presentation: An 89-year-old woman was transferred to our hospital due to back pain after a fall and sudden-onset left hemiparesis. We performed MT because three-dimensional computed tomography angiography (3D-CTA) revealed right middle cerebral artery (MCA) occlusion. The access route was Type 3 aortic arch. The abdominal aorta and common iliac artery were tortuous and partially dissected, and she had a lumbar vertebra fracture. We selected dTRA in consideration of safety, ease of access, and less postoperative postural restriction. The first pass resulted in complete recanalization using an aspiration catheter and stent retriever. Her symptoms rapidly improved and she was discharged with a modified Rankin Scale score of 1.
Conclusion: dTRA in MT may be a treatment option.
... For vulnerable plaques or marked stenosis patients in whom distal embolism may occur, carotid artery stenting (CAS) can be safely performed by adopting the proximal balloon protection (PBP) method with a balloon guiding catheter. [1][2][3][4] Regarding transbrachial carotid artery stenting (TB-CAS), several studies reported a method of CAS under PBP with a balloon guiding catheter, [5][6][7][8] but no study has adopted the PBP method during transradial carotid artery stenting (TR-CAS). We report two patients for whom TR-CAS using a 6 Fr Simmons-type guiding sheath was performed by inserting a 6 Fr balloon guiding catheter coaxially for stenotic-site passage under PBP and then switching to distal balloon protection. ...
... Ma Ultra (Medtronic) in the absence of a sheath, and guiding it into the common carotid artery. 5,6) However, caution is needed to not damage the balloon on insertion into blood vessels. Furthermore, Nishida et al. 7) reported TB-CAS in which a 5.2 Fr balloon catheter (5.2 Fr Serecon MP catheter; Terumo Clinical Supply Co., Ltd., Gifu, Japan) was inserted into a 7 Fr Shuttle (COOK Medical, Bloomington, IN, USA), and PBP was switched to total distal balloon protection (TDBP) using two Carotid Guardwires. ...
Objective: We report two patients for whom the proximal balloon protection (PBP) method was used during transradial carotid artery stenting (TR-CAS).
Case Presentations: Case 1 was a 79-year-old male. TR-CAS for acute occlusion of the internal carotid artery was performed. A 6 Fr balloon guiding catheter was introduced into a 6 Fr guiding sheath, and CAS was conducted by passing through the lesion under PBP. Case 2 was an 83-year-old male. TR-CAS was performed to treat marked stenosis of the internal carotid artery. It was difficult to pass the catheter through the lesion, but PBP with a balloon guiding catheter enhanced the supporting power, facilitating lesion passage, and CAS was successful.
Conclusion: No study has reported PBP during TR-CAS, but we were able to perform PBP during TR-CAS by adopting this method, and the support for lesion passage may be enhanced. This method may be useful for patients at risk of distal embolism or for those in whom lesion passage is difficult.
... On the other hand, if it is impossible to advance a guidewire, it should be switched to a Simmonstype guiding catheter (Neuro EBU 8-Fr; Gadelius Medical), or the parent and child balloon technique, in which a Guardwire system and guiding catheter's balloon are concertedly used, 8) should be adopted. Furthermore, there is an option to change the approaching site from the femoral artery to the radial 9,10,12) /brachial [13][14][15] /common carotid arteries, 11,16) but extra time is required to add a puncture site; 7,11) therefore, the option is considered not appropriate for thrombectomy as emergency treatment. However, in institutions where the above devices are not equipped, these devices cannot be used on emergencies, such as thrombectomy. ...
... A study reported the usefulness of a balloon guiding catheter for thrombectomy, 18) and another study introduced a procedure to insert a balloon guiding catheter through the brachial artery for carotid artery stenting. 15) In our method, a balloon guiding catheter was not used, considering the rapidity, simplicity, and accessibility. However, in Case 4, incomplete recanalization may have been associated with the absence of proximal blockage. ...
Objective: For thrombectomy, it is sometimes difficult to advance a guiding catheter using the transfemoral artery approach. In this study, we report five patients in whom intraoperative switching to the transbrachial artery approach led to successful results.
Case Presentations: This procedure was performed for five patients in whom it was difficult to guide a catheter using the transfemoral artery approach. A 6-Fr sheath-introducer was newly inserted into the brachial artery, and an aspiration catheter was directly inserted into the sheath’s insertion opening using an attached inserter and advanced to reach a target vessel. Subsequently, thrombectomy with the aspiration method or a stent retriever was conducted, and Thrombolysis in cerebral infarction (TICI) 2b or higher recanalization was achieved in four patients in a relatively short time.
Conclusion: The direct aspiration catheter insertion technique using the transbrachial approach may be useful as an alternative method for patients in whom transfemoral approach is difficult.
Herein, we report a case of carotid artery stenting with proximal flow protection for severe stenosis of the left internal carotid artery using transbrachial and transradial artery approaches. Because an abdominal aortic aneurysm was present, we avoided the transfemoral approach. The procedure was successfully performed with a combination of an 8-Fr balloon guide catheter and microballoon catheter on separate axes. No complications such as pseudoaneurysm, thrombosis, or dissection were observed at the puncture site. The patient was discharged without complications and showed good outcomes at 3 months. This technique may offer a useful alternative for patients with severe stenosis who cannot be treated using a femoral artery approach.
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Objectives: Azygos anterior cerebral artery (ACA) is a well-known anomaly of the second segment of the ACA. Although cases of intracerebral aneurysms related to this anomaly have been reported, acute ischemic stroke (AIS) related to the azygos ACA is extremely rare.
Case Presentations: An 84-year-old man developed disturbance of consciousness (Glasgow Coma Scale [GCS] E3V1M5), quadriparesis and aphasia, with a National Institutes of Health Stroke Scale (NIHSS) score of 32. Magnetic resonance imaging (MRI) showed no early ischemic changes, although a head magnetic resonance angiogram (MRA) demonstrated a single A2 trunk without any A3 branches that were suspected bilateral ACA occlusions. Mechanical thrombectomy for the occluded A2 trunk with contact aspiration using a Penumbra 4MAX aspiration catheter was performed, and the clot was retrieved and complete recanalization was achieved after two attempts (Thrombolysis in Cerebral Infarction scale 3) without any complications (onset to recanalization time: 187 min). The final angiogram demonstrated the recanalization of the single A2 and bilateral A3 branches, so we diagnosed as azygos ACA occlusion. MRI performed the next day revealed several small infarctions in bilateral frontal lobes, but ischemic symptoms gradually improved. NIHSS score decreased to two in 2 weeks and modified Rankin Scale (mRS) score at 90 days was one.
Conclusion: In this case, occlusion of the azygos ACA led to a large ischemic penumbra that spread widely and bilaterally in the ACA area, resulting in sudden onset of severe ischemic symptoms, including quadriparesis and aphasia. However, due to complete and rapid recanalization with contract aspiration, a large part of the ACA territory bilaterally was salvaged and the patient recovered extremely well.
Objective: Right aortic arch is an uncommon anatomical anomaly. Therefore, it is rare to encounter patients with such condition in clinical settings. Herein, we report the case of a man with symptomatic internal carotid artery stenosis with the right aortic arch.
Case Presentation: An 80-year-old man received medical treatment after experiencing left-sided cerebral infarction. He was admitted due to dysarthria and right hemiparesis. Magnetic resonance imaging revealed flesh infarctions in the left cerebral hemisphere and progression of left internal carotid artery stenosis. Computed tomography angiography showed right aortic arch with Kommerell diverticulum, and the first branch arising from the aortic arch was the left common carotid artery, followed by the right common carotid artery, right subclavian artery, and left subclavian artery. The origin of the left common carotid artery was significantly lower than the top of the aorta, and the aortic plaque was identified. Revascularization surgery of the left internal carotid artery stenosis was planned to prevent recurrent stroke, and carotid artery stenting was performed via the right brachial artery without any complications.
Conclusion: A preoperative neuroradiological imaging study that considers the approach route is necessary and useful for endovascular therapy.
Although transfemoral approach is common for thrombectomy, it is time-consuming in some patients such as bovine type aortic arch, type 3 aorta, and extreme arterial tortuosity. The patient is a 90-year-old female presented with right paralysis and aphasia, NIHSS16. Cerebral CT/CTA showed a cerebral infarction due to a left middle cerebral artery occlusion. CTA of aortic arch showed a chronic aortic dissection, bovine type aortic arch, and type 3 aorta. Mechanical thrombectomy was performed via the right transbrachial approach with TICI 2b recanalization. Transbrachial approach can be an effective choice for the difficult approach of mechanical thrombectomy. Preoperative evaluation of the aortic arch is effective for selecting the appropriate approach route.
Objective: We report a novel technique of the proximal balloon protection (PBP) during internal carotid artery stenotic lesion crossing, and the following total distal balloon protection (TDBP) for transbrachial carotid artery stenting (TB-CAS) with 7Fr-guiding sheath.
Case presentation: A 83-year-old male patient presented with an asymptomatic severe stenosis in the right internal carotid artery (ICA) complicated with ipsilateral occipital-vertebral artery anastomosis and severe aortic arch atherosclerosis. A 7Fr-guiding sheath was inserted into the right brachial artery and navigated into the right common carotid artery (CCA). The PBP was obtained by inflating the separately advanced GuardWire in the external carotid artery (ECA) and the 5.2Fr Selecon MP Catheter in the distal CCA. The TDBP was achieved with the following process; (1) a second GuardWire was navigated into the distal ICA under the PBP through the Selecon MP Catheter, and then inflated to achieve the distal protection, (2) The Selecon MP Catheter was deflated and withdrawn, (3) the inflated GuardWires in the ICA and ECA complete the TDBP. Then TB-CAS was performed under TDBP without any complication.
Conclusion: This protection technique enables the PBP and the subsequent TDBP with a 7Fr-guiding sheath and may be useful when performing TB-CAS.
Objective: Authors describe our experience of transbrachial coil embolization for posterior circulation aneurysms by using a 4 French (Fr.) guiding sheath.
Case Presentations: We retrospectively evaluated the technical feasibility, access site complications, and concomitant use of adjunctive techniques on transbrachial coil embolization from April to July 2015.
Results: Three patients underwent transbrachial coil embolization for a posterior circulation aneurysm using a 4 Fr. guiding sheath. The patients’ average age was 78.7 years (range 74–87 years). Two patients had a ruptured aneurysm (two aneurysms), and one had an unruptured aneurysm. The site of the aneurysms included a right vertebral artery-posterior inferior cerebellar artery bifurcation, basilar bifurcation, and basilar artery-left superior cerebellar artery bifurcation. All procedures were successfully performed using the brachial approach and balloon neck remodeling technique. No periprocedural or access site complications were observed.
Conclusion: Transbrachial coil embolization of a posterior circulation aneurysm may be a useful alternative method, especially in elderly patients with an undesirable arterial anatomy for a transfemoral approach. Additionally, the 4 Fr. guiding sheath is a useful device for this approach, as it enables the adjunctive techniques and minimizes the brachial puncture size.
This paper focuses on cases with difficult access for carotid artery stenting (CAS), and discusses management of such cases.
Of 135 consecutive patients who underwent CAS from January 2012 to December 2015 in our department, 11 (5.2%) had a difficult access route. In 3 cases with stenosis or elongation of the iliac arteries, we selected a smaller guiding sheath to pass through the artery. In one case with elongation of the abdominal aorta, a long and kink-resistant sheath was used to perform CAS. In 7 cases with a difficult femoral approach, CAS was performed via the right brachial artery. All 11 CAS procedures were uneventful without any perioperative complications.
Even in cases with a difficult access route, CAS can be performed safely with several techniques as described in this article.
Objective: A transfemoral approach is usually used for carotid artery stenting (CAS), but postoperative recovery is painful. A transbrachial approach may result in puncture site complications, pain in the forearm, or sensory loss, and can also result in median nerve palsy due to subcutaneous bleeding. To reduce the postoperative burden on the patient and mitigate the potential for complications, transradial CAS (TR-CAS) was performed at our institution, as reported here.
Methods: TR-CAS was performed on 20 lesions in 19 patients (4 female, 15 male; mean age, 69.9 years [range 59-83]; 14 symptomatic lesions, 6 asymptomatic lesions) from August 2010 to December 2011. The right carotid artery was stented in 17 patients and the left was stented in 3.
Results: Stents were placed in all patients. Cerebellar infarction was noted in 1 patient and subcutaneous bleeding in the forearm was noted in another. No puncture site problems were noted. Caution was required since protracted radial artery puncture could lead to vasospasms, the guidewire could be misdirected into small branches, and patients could have anatomical variations such as absence of the ulnar artery or the presence of an ulnar loop.
Conclusion: TR-CAS is not a difficult procedure for an interventional neuroradiologist and is less invasive for the patient.
Objectives:
Lower limbs arterial disease (LLAD) portends high risk of cardiovascular events. Yet, the prevalence of significant occult coronary artery (CAD) and cerebrovascular (CVD) disease in patients without CAD and CVD has not been widely investigated. The purpose of this study was to evaluate the prevalence and severity of CAD and CVD in patients with LLAD of the lower extremities.
Methods:
From January 2008 through December 2011 we studied 200 consecutive patients admitted for symptomatic LLAD, with normal global and regional systolic function, no symptoms of angina or dyspnea. During hospital admission all patients underwent carotid Doppler study and invasive angiography.
Results:
Significant CAD was observed in 110 of 200 (55%) patients. Fifty-eight (53%) patients with significant CAD showed either left main (n = 7), 3 vessels (n = 35) or proximal left anterior descending (n = 16) CAD, corresponding to 29% of total cohort. CVD was detected in 86(43%) patients (69% with concomitant CAD), including 30(35%) with severe and 15(17%) with significant disease. In thirty-two (37%) patients with CVD either left main (n = 4), 3 vessels (n = 18) or proximal left anterior descending (n = 10) CAD was observed. The percent of patients with left main, 3 vessel or proximal left anterior descending stenosis among those with CVD was significantly higher (37%; p = 0.03) compared to those without CVD.
Conclusions:
Severe asymptomatic CAD and CVD are quite prevalent in LLAD, and 29% of patients fulfill indications for coronary revascularization. Cost-effective strategies to detect occult CAD or CVD in LLAD patients need to be investigated in large multicenter studies.
Background:
The transfemoral approach has been a common technique for carotid artery stenting (CAS). When aortic or peripheral arterial conditions limit the transfemoral approach, the transbrachial approach may be used as an alternative. The purpose of our study was to report initial experiences of CAS with a novel sheath guide specifically designed for transbrachial carotid cannulation.
Methods:
Patients who underwent transbrachial CAS with a novel sheath guide between May 2011 and July 2012 were analyzed. The sheath guide has an internal diameter of 6 Fr (2.24 mm, 0.088 inch) and is 90 cm long with a soft distal part and a particular distal shape like a modified Simmons catheter.
Results:
Sixty-two patients underwent transbrachial CAS with the sheath guide. Transbrachial carotid cannulation was easy and successful and CAS procedures were performed easily through the sheath guide in every case. No sheath-related periprocedural complications occurred.
Conclusions:
The sheath guide specifically designed for transbrachial carotid cannulation is useful for transbrachial CAS.
Background A study was undertaken to investigate the feasibility, safety and effectiveness of emergency carotid artery stenting (eCAS) for a high-grade carotid stenosis with intraluminal thrombus (ILT) with or without proximal flow control (PFC).
Methods Patients with acute ischemic stroke included in the analysis were those who were admitted between 2001 and 2010 with serious neurological symptoms, without a large high-intensity area of diffusion-weighted images and who underwent eCAS for a high-grade carotid stenosis with ILT. Patients underwent eCAS without PFC until 2004 (group C) and under PFC after 2004 (group P). The National Institutes of Health Stroke Scale (NIHSS) score on admission, just before CAS and 7 days after CAS as well as the 3-month modified Rankin Scale were investigated.
Results Fifty-six patients underwent eCAS, eight of whom had a high-grade stenosis with ILT. Four of the eight patients were in group C and four were in group P. Probable distal embolism associated with eCAS occurred in two cases in group C and in none in group P. In groups C and P the median 7-day NIHSS scores were 15 and 5, respectively (p<0.05) and the median 3-month modified Rankin Scale scores were 4 and 2, respectively (p<0.05), but there were no significant differences between the two groups in the NIHSS scores on admission and just before CAS.
Conclusion In stroke patients with a high-grade carotid stenosis with ILT, eCAS under PFC is safer and more effective in achieving a favorable clinical outcome than eCAS without PFC.
Purpose:
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.
Methods:
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.
Results:
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.
Conclusion:
CAS via a right radial or brachial approach is safe and effective in patients with LICA stenosis and types 1 or 2 bovine arch.
Objectives:
To demonstrate safety and efficacy of new 6 Fr intra-aortic balloon pumping (IABP) system.
Background:
Access-site complications have been reported to increase adverse events following PCI. Some reports have shown access-site complications in conventional 8-Fr compatible IABP system. The new 6 Fr IABP system may reduce the complication rate due to the smaller size.
Methods:
We extracted medical records for patients who underwent elective percutaneous coronary intervention under prophylactic 6 Fr or 8 Fr IABP assistance from January 2006 to December 2009 at Tokai University School of Medicine. The clinical outcomes were compared between 6 Fr and 8 Fr or between transfemoral and transbrachial IABP.
Results:
A total of 42 cases were extracted, including 20 cases using 6 Fr IABP (47.6%) and 22 cases using 8 Fr IABP (52.4%). The 6 Fr IABP included 15 cases of transbrachial approach (75.0%) and 5 cases of transfemoral approach (25.0%). All cases of 8 Fr IABP were via transfemoral approach. The bedrest time was clearly shorter in the 6 Fr IABP group (75.8 ± 139.8 minutes vs 360.0 ± 104.7 minutes in the 8 Fr IABP group; P<.001). Bedrest time and duration of hospitalization were shorter in the transbrachial IABP group (0.0 ± 0.0 minutes and 1.0 days [interquartile range, 1.0- 2.0 days] vs 288.0 ± 107.3 minutes and 5.0 days in the transfemoral group [interquartile range, 3.0-8.0]; P<.001). Access-site complications were 0% with the 6 Fr system, but 13.6% with the 8 Fr IABP system.
Conclusions:
This study demonstrated that the 6 Fr IABP system and its transbrachial application may be feasible because of lower complication rates.
The objective of this study was to compare the cerebral embolic load of filter-protected versus proximal balloon-protected carotid artery stenting (CAS).
Randomized trials comparing filter-protected CAS with carotid endarterectomy revealed a higher periprocedural stroke rate after CAS. Proximal balloon occlusion may be more effective in preventing cerebral embolization during CAS than filters.
Patients undergoing CAS with cerebral embolic protection for internal carotid artery stenosis were randomly assigned to proximal balloon occlusion or filter protection. The primary endpoint was the incidence of new cerebral ischemic lesions assessed by diffusion-weighted magnetic resonance imaging. Secondary endpoints were the number and volume of new ischemic lesions and major adverse cardiovascular and cerebral events (MACCE).
Sixty-two consecutive patients (mean age: 71.7 years, 76.4% male) were randomized. Compared with filter protection (n = 31), proximal balloon occlusion (n = 31) resulted in a significant reduction in the incidence of new cerebral ischemic lesions (45.2% vs. 87.1%, p = 0.001). The number (median [range]: 2 [0 to 13] vs. 0 [0 to 4], p = 0.0001) and the volume (0.47 [0 to 2.4] cm(3) vs. 0 [0 to 0.84] cm(3), p = 0.0001) of new cerebral ischemic lesions were significantly reduced by proximal balloon occlusion. Lesions in the contralateral hemisphere were found in 29.0% and 6.5% of patients (filter vs. balloon occlusion, respectively, p = 0.047). The 30-day MACCE rate was 3.2% and 0% for filter versus balloon occlusion, respectively (p = NS).
In this randomized trial of patients undergoing CAS, proximal balloon occlusion as compared with filter protection significantly reduced the embolic load to the brain.
Each of the embolic protection devices used in carotid artery stenting (CAS) has advantages and disadvantages. The prospective, multicenter, single-arm EMPiRE Clinical Study investigated a proximally placed device (GORE Flow Reversal System) that provides distal neuroprotection during CAS by reversing blood flow in the internal carotid artery, thereby directing emboli away from the brain.
The study evaluated 30-day outcomes in 245 pivotal high-surgical-risk patients (mean age, 70 years; 32% symptomatic; 16% ≥80-years old) with carotid stenosis who underwent CAS using the flow reversal system. The primary endpoint was a major adverse event (MAE; stroke, death, myocardial infarction, or transient ischemic attack) within 30 days of CAS. The MAE rate was compared with an objective performance criterion (OPC) derived from CAS studies that included embolic protection.
The MAE rate was 4.5% (11 patients; P=0.002 compared with the OPC). The stroke and death rate was 2.9%. No patient had a major ischemic stroke. Six patients (2.4%) had intolerance to flow reversal. The death and stroke rates in the symptomatic, asymptomatic, and octogenarian subgroups were 2.6, 3, and 2.6%, respectively, meeting American Heart Association guidelines for carotid endarterectomy.
The stroke and death rate in this study was among the lowest in CAS trials. The results indicate that the flow reversal system is safe and effective when used for neuroprotection during CAS and that it provides benefits in a broad patient population.
The aim of this study was to assess the safety and effectiveness of carotid artery stenting (CAS) with proximal cerebral protection in patients showing string sign at carotid angiography.
Presence of string sign is a well-known factor for adverse events in patients with severe carotid artery disease undergoing CAS.
We used retrospective analysis of a cohort of patients who underwent carotid angiography with the intention to undergo carotid stenting and had angiographically documented string sign in the target lesion.
From October 2006 to August 2007, 25 patients (21 men and 4 women, mean age 70.9 +/- 8.7 years) presented with string sign during carotid angiography. This was 6.0% of a total of 416 patients studied during the time of the study. Twenty patients (80.0%) were symptomatic, and 5 (20.0%) were asymptomatic. Carotid artery stenting was performed successively in all patients. Proximal cerebral protection was applied in all but 1 patient. The 30-day death/stroke rate was 0%. At 12-month follow-up neurological events did not occur; 1 patient developed a nonfatal myocardial infarction, and another patient died from noncardiac cause. The 12-month death/stroke rate was 4.0%.
Carotid stenting under proximal cerebral protection seems to be a feasible and safe procedure to manage patients with severe carotid stenosis in presence of angiographic string sign. Further prospective trials are required to prove efficacy of CAS in larger study populations.