Elsevier

World Neurosurgery

Volume 81, Issues 3–4, March–April 2014, Pages 543-548
World Neurosurgery

Peer-Review Report
Proximal versus Distal Protection During Carotid Artery Stenting: Analysis of the Two Treatment Approaches and Associated Clinical Outcomes

https://doi.org/10.1016/j.wneu.2013.10.031Get rights and content

Objective

Cerebral protection device utilization during carotid artery stenting (CAS) has been shown to decrease risk of perioperative stroke. The two most commonly used devices are distal filters and proximal protection devices, which allow blood flow cessation or flow reversal. The goal of the present study was to examine anatomic and morphologic characteristics of the treated lesions using each type of cerebral protection device and compare clinical 30-day adverse event rates between the two cerebral protection groups.

Methods

We conducted a single-center, retrospective review of consecutive CAS cases with proximal protection devices that were matched with CAS cases using distal filter protection devices based on indication (symptomatic vs. asymptomatic), age, and gender. We reviewed clinical, anatomic, and morphologic characteristics of the stented lesions in cases of proximal or distal protection and also studied the rate of major adverse events within the first 30 days after the procedure.

Results

We identified a total of 70 patients treated with proximal protection devices who were matched in a blinded fashion to 70 cases with distal protection. There was a significantly higher number of high-risk lesions in patients who had CAS using proximal protection devices (P = 0.009). There was no significant difference in overall frequency of 30-day adverse outcomes (transient ischemic attack/stroke/reperfusion hemorrhage/death) between the two groups (P = 1.0).

Conclusions

Our study is the first attempt (to our knowledge) to review and compare anatomic and morphologic characteristics of the stented lesions in cases of proximal versus distal protection for CAS. Our data indicate that in properly selected patients both approaches could be equally safe and effective.

Introduction

Carotid artery stenting (CAS) has become established as a less invasive alternative procedure to carotid endarterectomy for patients with carotid artery stenosis. Systematic reviews of previously published studies on protected and unprotected CAS indicate that the use of cerebral protection devices decrease the risk of perioperative stroke 4, 7. Distal filters (e.g., Filter Wire EZ; Boston Scientific, Natick, Masssachusetts, USA) and Emboshield NAV6 (Abbott Vascular, Abbott Park, Illinois, USA) are the most commonly used type of protection devices and have been incorporated into major recent trials. An alternative approach is to use proximal protection with the MO.MA device (Invatec, Roncadelle, Italy) or the GORE Flow Reversal System (WL Gore and Associates, Flagstaff, Arizona, USA) that create blood flow cessation or flow reversal during the stenting procedure by simultaneous balloon occlusion of the external and common carotid artery. Recent studies showed a reduction in the number of ischemic lesions documented by diffusion-weighted magnetic resonance imaging (DWI-MRI) with the proximal protection approach in comparison to the distal protection approach, although that did not translate into a reduction in adverse clinical outcomes 2, 8.

The choice of a particular protection approach depends on several factors, including anatomic features of the carotid vessel (e.g., tortuous or diseased internal carotid artery distal to the lesion), stenotic lesion characteristics (e.g., hemorrhagic plaque or intraluminal thrombus), and operator experience. The goal of this study was to examine anatomic and morphologic characteristics of the stenotic lesions and compare clinical 30-day adverse event rates between the two cerebral protection groups.

Section snippets

Study Design, Setting, and Population

We conducted a single-center, retrospective review of consecutive cases of CAS in which proximal protection devices were used between January 2006 and March 2012. All procedures were done by endovascular neurosurgeons proficient in performing the stenting procedure using both proximal and distal protection devices. Patients with symptomatic and asymptomatic carotid artery stenosis were included. Patients were considered symptomatic if they had an ischemic event corresponding to the affected

Descriptive Data

We identified a total of 70 patients treated with proximal protection devices during the CAS procedure. Of those, 49 patients were treated using the MO.MA proximal protection device (Invatec) and 21 patients were treated using the GORE Flow Reversal System (WL Gore and Associates). These patients were matched (based on stenosis symptomatology, age, and gender) with 70 patients treated for CAS using distal filter protection devices (Filter Wire EZ [Boston Scientific] or Emboshield NAV6 [Abbott

Discussion

In the present study, we reviewed anatomic and morphologic characteristics of the stenotic lesions and the decision-making process when choosing proximal versus distal protection devices in patients undergoing CAS procedures performed by endovascular-trained neurosurgeons proficient in using both types of protection devices. We found that in 56 of 140 patients both types of devices could be used. Interestingly, distal filters were used in most of those patients (84%).

Other investigators have

Conclusion

Our study is the first attempt (to our knowledge) to review and compare anatomic and morphologic characteristics of stented lesions in cases of proximal versus distal protection for CAS. Our data indicate that in properly selected patients both approaches could be equally safe and effective. Further prospective studies focusing on clinical outcomes and not only imaging surrogates for cerebral embolization (such as DWI-MRI or transcranial Doppler imaging) are needed.

Acknowledgment

We thank Debra J. Zimmer for editorial assistance.

References (19)

There are more references available in the full text version of this article.

Cited by (21)

  • Proximal embolic protection versus distal filter protection versus combined protection in carotid artery stenting: A systematic review and meta-analysis

    2018, Cardiovascular Revascularization Medicine
    Citation Excerpt :

    After screening titles and abstracts, 47 articles were retrieved for full-text evaluation and 29 studies satisfied the predetermined search criteria and were included in this meta-analysis (Fig. 1). From them, 11 were RCTs [13,14,24–32] and 18 were observational studies [7,9,10,16,33–46] including in total 16,307 patients. Risk of bias for RCTs is presented separately in Supplementary Table 1.

View all citing articles on Scopus

Conflict of interest statement: Dr. Hopkins receives grant/research support from Toshiba; serves as a consultant to Abbott, Boston Scientific, Cordis, Micrus, and Silk Road; holds financial interests in AccessClosure, Augmenix, Boston Scientific, Claret Medical, Endomation, Micrus, and Valor Medical; holds a board/trustee/officer position with Access Closure and Claret Medical; serves on Abbott Vascular's speakers' bureau; and has received honoraria from Bard, Boston Scientific, Cleveland Clinic, Complete Conference Management, Cordis, Memorial Health Care System, and the Society for Cardiovascular Angiography and Interventions (SCAI). Dr. Kass-Hout received research funding from Genentech Medical Educational and Research Department. Dr. Levy receives research grant support, other research support (devices), and honoraria from Boston Scientific* and research support from Codman & Shurtleff, Inc. and ev3/Covidien Vascular Therapies; has ownership interests in Intratech Medical Ltd. and Mynx/Access Closure; serves as a consultant on the board of Scientific Advisors to Codman & Shurtleff, Inc.; serves as a consultant per project and/or per hour for Codman & Shurtleff, Inc., ev3/Covidien Vascular Therapies, and TheraSyn Sensors, Inc.; and receives fees for carotid stent training from Abbott Vascular and ev3/Covidien Vascular Therapies. Dr. Levy receives no consulting salary arrangements. All consulting is per project and/or per hour. (*Boston Scientific's neurovascular business has been acquired by Stryker.) Dr. Mokin received an educational grant from Toshiba Medical Systems. Dr. Siddiqui received research grants from the National Institutes of Health (co-investigator: NINDS 1R01NS064592-01A1—not related to the present work) and the University at Buffalo (Research Development Award); holds financial interests in Hotspur, Intratech Medical, StimSox, and Valor Medical; serves as a consultant to Codman & Shurtleff, Inc., Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, and Penumbra; belongs to the speakers' bureaus of Codman & Shurtleff, Inc. and Genentech; serves on an advisory board for Codman & Shurtleff; and has received honoraria from Peripheral Angioplasty and All That Jazz and American Association of Neurological Surgeons' courses, an Emergency Medicine Conference, Genentech, Neocure Group LLC, and from Abbott Vascular and Codman & Shurtleff, Inc. for training other neurointerventionists in carotid stenting and for training physicians in endovascular stenting for aneurysms. Dr. Siddiqui receives no consulting salary arrangements. All consulting is per project and/or per hour. Dr. Snyder serves as a consultant to, a member of the speakers' bureau, and has received honoraria from Toshiba. He serves as a member of the speakers' bureau for and has received honoraria from ev3 and The Stroke Group. Dr. Dumont, Ms. Chi, Mr. Mangan, and Dr Sorkin report no financial relationships.

View full text