The problem of microembolism in carotid stenting and its solution

  • Yu.V Cherednychenko Dnipropetrovsk Regional Clinical Hospital named after I.I. Mechnikov
Keywords: carotid stenting, internal carotid artery, microembolism, endovascular methods.

Abstract

Objective – to reduce of frequency of microembolism in carotid stenting with optimizing the choice of anti-embolic protection and using double-layer stents.

Materials and methods. In the endovascular center of the Dnipropetrovsk Regional Hospital named after I.I. Mechnikov 41 patients (24 men and 17 women, aged from 56 to 81 years, average age – 66.9 year) underwent carotid stenting with the use of Casper double-layer carotid stents (Micro- Vention) and a differentiated approach to the choice of anti-embolic protection for the last 9 months. 47 operations of carotid stenting were performed. Before carotid stenting and in the early postoperative period (1-2 days), patients underwent MRI of the brain with a DWI protocol to determine the appearance of new embolic ischemic lesions in the postoperative period. Distal anti-embolic devices were used in all cases where the risk of their use was not regarded as increased (n = 43). The proximal anti-embolic device Mo.MaUltra (Medtronic) was used in three cases with extended stenosis, «complicated» subtotal stenosis. The method of combined usage of the proximal anti-embolic device Mo.MaUltra and the distal anti-embolic device was used in a case with complicated subtotal extended carotid stenosis and temporary carotid artery occlusion intolerance. In all observations plaques in the initial segment of the internal carotid arteries had signs that increased the risk of microembolism in the postoperative period with the usage of not double-layered design carotid stents. Therefore, we used Casper double-layer stents in these cases.

Results. Elimination of the carotid stenosis was achieved in 100 % of cases. After the Casper stent implantation, if there were ulcerations, angiographically, there was no contrasting under the stent in ulcerations, or prolonged stagnation in them. There were also no angiographic signs of plaque prolapse through the structure of the stent. MRI of the brain in the DWI-regime did not show any new ischemic lesions in a control study after carotid stenting (1-2 days). There was anneurological improvement in 85.4 % of cases (35 patients). The condition of other patients remained stable, without deterioration in the neurological status. The clinic of ischemic stroke did not develop in any patient for the period from 30 days to 9 months after carotid stenting. Moderate hyperperfusion syndrome developed in the postoperative period in 2 cases (4.9 %) with complete regression of symptoms in the subsequent period. Postoperative mortality was 0 %. There were no local complications at the artery puncture site.

Conclusions. Analysis of the results of treatment of patients with carotid stenoses with the usage of double-layer stents and a differentiated choice of the method of anti-embolic protection showed that this approach can lead the carotid stenting technique to a new level of efficiency and safety.

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References

Ringleb PA, Allenberg JR, Berger J et al. 30 day results from the space trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomized non-inferiority trial. Lancet. 2006;368:1239-47. View Recordin Scopus

Stabile E, Sannino A, Schiattarella GG et al. Cerebral embolic lesions detected with diffusion-weighted magnetic resonance imaging following carotid artery stenting: a meta-analysis of 8 studies comparing filter cerebral protection and proximal balloon occlusion. JACC Cardiovasc. Interv. 2014;7(10):1177-83. Epub 2014 Sep 17. doi:10.1016/jjcin.2014.05.019

Orlandi G, Fanucchi S, Fioretti C et al. Characteristics of cerebral microembolism during carotid stenting and angioplasty alone. Arch. Neurol. 2001;58(9):1410-3.

Maggio P, Altamura C, Landi D et al. Diffusion-weighted lesions after carotid artery stenting are associated with cognitive impairment. J. Neurol. Sci. 2013;328(1-2):58-63. doi: 10.1016/jjns.2013.02.019. Epub 2013 Mar 17

Mas JL, Chatellier G, Beyssen B et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N. Engl. J. Med. 2006;355:1660- 71. doi: 10.1056/NEJMoa061752

Hashimura N, Mutoh T, Matsuda K, Matsumoto K. Evaluation and management of plaque protrusion or thrombus following carotid artery stenting. Neurol. Med. Chir. (Tokyo). 2015;55(2):149-54. Published online 2015 Jan 23. doi: 10.2176/nmc.oa.2014-0105

Keun Young Park, Dong Ik Kim, Byung Moon Kim et al. Incidence of embolism associated with carotid artery stenting: open-cell versus closed-cell stents. Journal of Neurosurgery. 2013;119,3:642-7. doi: 10.3171/2013.5.JNS1331.

Kassavin DS, Clair DG. An update on the role of proximal occlusion devices in carotid artery stenting. J. Vasc. Surg. 2017;65(1):271-5. Epub 2016 Nov 19. doi:10.1016/jjvs.2016.09.048

Brott TG, Howard G, Roubin GS et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N. Engl. J. Med. 2016;374:1021-31. doi: 10.1056/NEJMoa1505215

Schnaudigel S, Groschel K, Pilgram SM, Kastrup A. New brain lesions after carotid stenting versus carotid endarterectomy: a systematic review of the literature. Stroke. 2008 Jun;39(6):1911-9. doi: 10.1161/ STROKEAHA.107.500603. Epub 2008 Apr 3.

de Donato G, Setacci F, Sirignano P. et al. Optical coherence tomography after carotid stenting: rate of stent malapposition, plaque prolapse and fibrous cap rupture according to stent design Eur. J. Vasc. Endovasc. Surg. 2013;45(6):579-87. doi: 10.1016/j.ejvs.2013.03.005. Epub 2013 Apr 10

Stabile E, Salemme L, Sorropago G et al. Proximal endovascular occlusion for carotid artery stenting: Results from a prospective registry of 1,300 patients. J. Am. CollCardiol. 2010;55:1661-7. doi:10.1016/j. jacc.2009.11.079

Richards CN, Schneider PA. Will mesh-covered stents help reduce stroke associated with carotid stent angioplasty? Vasc. Surg. 2017;30(1):25-30. Epub 2017 Apr 27. doi:10.1053/j.semvascsurg.2017.04.007

Brott TG, Hobson RW II, Howard G et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N. Engl. J. Med. 2010;363(1):11-23. doi: 10.1056/NEJMoa0912321

Maggio P, Altamura C, Lupoi D et al. The role of white matter damage in the risk of periprocedural diffusion-weighted lesions after carotid artery stenting. Cerebrovasc. Dis. Extra. 2017;7(1):1-8. doi: 10.1159/000452717. Epub 2017 Jan 27.

Published
2018-03-01
How to Cite
Cherednychenko, Y. (2018). The problem of microembolism in carotid stenting and its solution. Ukrainian Interventional Neuroradiology and Surgery, 23(1), 89-97. https://doi.org/10.26683/2304-9359-2018-1(23)-89-97