Clinical Research
Significance of Combining Distal Filter Protection and a Guiding Catheter With Temporary Balloon Occlusion for Carotid Artery Stenting: Clinical Results and Evaluation of Debris Capture

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Background

Carotid artery stenting (CAS) with distal filter protection allows for continuous cerebral perfusion. However, this procedure has been reported to be associated with a greater risk of debris migrating into the cerebral arteries. To improve the extent of debris capture, we used a guiding catheter with temporary balloon occlusion and temporary aspiration from the common carotid artery.

Methods

Eighty-one stenoses were treated with CAS using distal filter protection; simple distal filter protection (conventional group, n = 50) or distal filter protection with temporary proximal flow control and blood aspiration was performed using a 9-F guiding catheter with a temporary balloon occlusion positioned at the common carotid artery (proximal occlusion group, n = 31). Clinical outcomes, rates of capturing visible debris, and new ischemic signals on diffusion-weighted magnetic resonance imaging (DWI) were evaluated.

Results

Events involving procedure-related emboli causing neurological deficits occurred in 6.0% (3/50) and 3.2% (1/31) of patients in the conventional and proximal occlusion groups, respectively (P = 1.0). The rates of visible debris capture by using the distal filter were 64.0% (32/50) and 29.0% (9/31) in the convention and proximal occlusion groups, respectively, being significantly lower in the proximal occlusion group (P < 0.01). New ischemic signals on DWI were detected in 44.0% (22/50) and 12.9% (4/31) of cases in the conventional and proximal occlusion groups, respectively, being significantly lower in the proximal occlusion group (P < 0.01).

Conclusions

Combining distal filter protection and a guiding catheter with temporary balloon occlusion in CAS significantly reduced visible debris captured by the distal filter and occurrence of small postprocedural cerebral infarctions detected by DWI.

Introduction

Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy for treating selected cases of carotid artery stenosis; however, the most serious complication of CAS, cerebral embolization, is potentially life-threatening.1, 2

There are three principal types of embolic protection devices (EPDs): distal filters,3 flow arrest systems using a distal balloon,4 and flow reversal systems.5 Primary advantages of filters are antegrade blood flow within the internal carotid artery (ICA) during CAS and visualization of the lesion during the procedure. However, distal filters have some disadvantages in terms of capture capacity. Many studies have shown that distal filter protection involves a greater risk of debris migration into the intracranial arteries during CAS than other EPDs.

In Japan, the distal filter protection device Angioguard XP (Cordis, Miami Lakes, FL) was firstly approved by the Ministry of Health, Labor and Welfare in October 2007. Other distal filter protection devices, such as FilterWire EZ (Boston Scientific, Natick, MA), were approved by April 2010, and the distal balloon protection device of PercuSurge GuardWire (Medtronic, Minneapolis, MN) was approved by November 2010. We mainly used Angioguard XP for filter-protected CAS. Many studies have reported that distal filter protection involves a higher risk of debris migration into intracerebral arteries.6, 7, 8, 9 Therefore, we conducted a trial application using a guiding catheter with temporary balloon occlusion and temporary aspiration from the common carotid artery (CCA) for the purpose of improving the extent of debris capture. Clinical results, rate of debris capture, and postprocedural ischemic signals on diffusion-weighted magnetic resonance imaging (DWI) were compared between simple distal filter protection and combination of a distal filter and a guiding catheter with temporary balloon occlusion. The usefulness of combining the use of the EPDs is also discussed.

Section snippets

Patients and Lesion Characteristics

Seventy-eight patients with 81 carotid artery stenoses were treated with distal filter protection between April 2008 and June 2011. In all patients treated between April 2008 and May 2009, a normal guiding catheter or guiding sheath was used. From June 2009 to June 2011, a 9-F guiding catheter with temporary balloon occlusion was used in cases with safe femoral artery access, except for cases with severe arteriosclerosis or aortic elongation. Symptomatic patients with at least 50% stenosis of

Patient Characteristics

Patient characteristics of the conventional and proximal occlusion groups are shown in Table I. There were no significant differences in age, sex, symptomatic versus asymptomatic status, stenotic ratio, stenotic lesions, presence of ulceration, or presence of calcification between the conventional and proximal occlusion groups. During the CAS procedure, there were no significant differences in the distal filter, stent, or postdilation balloon diameter between the two groups.

Clinical Results

Clinical results of

Discussion

The primary advantages of distal filters are preservation of the antegrade blood flow in the ICA during CAS and visualization of the lesion during treatment. Distal filter protection devices have some disadvantages. Small particulate debris can pass through the pores of the filter if it is smaller than 100 μm, and the filter itself can damage the surrounding vessel wall, which can subsequently result in dislodgement of vessel wall fragments and clots as a result of adverse movement of an

Conclusions

The combined use of a guiding catheter with temporary balloon occlusion and a distal filter, as described herein, has the advantages of filter protection for antegrade ICA blood flow and a decreased debris capture by the distal filter. These properties collectively reduce the prevalence of the ischemic events during CAS.

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