Protection Filter-Related Events in Extracranial Carotid Artery Stenting: A Single-Center Experience

Abstract

Purpose:

To report the complications, rescue procedures, and consequences related to the use of an embolus protection filter during carotid artery stenting (CAS).

Methods:

A retrospective review was undertaken of 72 patients (58 men; mean age 70.0±8.2 years, range 56–87) with extracranial atherosclerotic carotid stenosis who underwent 77 CAS procedures under filter protection. Filter-related events and rescue procedures according to each procedural step were retrospectively evaluated on CAS angiograms. In addition, neurological events and outcomes were also assessed.

Results:

CAS using a filter was successful in 99% of cases, and the overall rate of minor stroke (n=1), major stroke (0), or mortality (n=1) was 2.6% at 30 days. Filter placement was successful in all cases. However, arterial tortuosity made it difficult for a filter to pass through the stenosis in 1 case; this was overcome with an additional supportive wire (0.018-inch). Filter-related events were flow impairment in 6 (7.8%), filter wedging in the catheter tip in 4 (5.2%), vasospasm >50% narrowing in 7 (9.1%), filling defects within the filter membrane in 5 (6.5%), retrieval failure with the provided retriever in 3 (3.9%), and insecure retrieval without filter collapse in 2 (2.6%). Flow impairment caused drowsy mentality and impaired verbal response in 4, which resolved after prompt filter retrieval. All the cases of filter wedging were resolved with a catheter pulled down into the stented segment to separate the filter element from the catheter tip. Significant vasospasm and filling defects were spontaneously resolved in all cases after filter retrieval. Inability to pass a retriever catheter through a stent was overcome with curved 5-F catheter manipulation in all 3 cases.

Conclusion:

The use of a filter during CAS may induce various angiographic or technical events at each step. For a severely stenotic and tortuous carotid lesion with difficult access, a filter may become trapped or irretrievable during flow arrest. Physicians should be aware of the preventive and rescue maneuvers to counter filter-related events, perhaps even considering another type of protection mechanism or carotid endarterectomy.

Keywords

carotid artery balloon angioplasty stent embolus protection device cerebral protection protection filter complications

Get full access to this article

View all access options for this article.

References

Yadav

Wholey

Kuntz

. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004; 351: 1493–1501.

CARESS Steering Committee. Carotid Revascularization using Endarterectomy or Stenting Systems (CARESS): Phase I clinical trial. J Endovasc Ther. 2003; 10: 1021–1030.

Howard

. Progress report of the carotid revascularization endarterectomy versus stent trial (CREST). International Stroke Conference. February 5, 2005; New Orleans, LA, USA.

Featherstone

Coward

Brown

. International carotid stenting study (ICSS). International Stroke Conference. February 5, 2005; New Orleans, LA, USA.

Gray

Hopkins

Yadav

. Protected carotid stenting in high-surgical-risk patients: The ARCHeR results. J Vasc Surg. 2006; 44: 258–268.

Mas

Chatellier

Beyssen

. Carotid angioplasty and stenting with and without cerebral protection: Clinical alert from the Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S) trial. Stroke. 2004; 35: e18–20.

Kastrup

Groschel

Krapf

. Early outcome of carotid angioplasty and stenting with and without cerebral protection devices: A systematic review of the literature. Stroke. 2003; 34: 813–819.

Théron

Courtheoux

Alachkar

. New triple coaxial catheter system for carotid angioplasty with cerebral protection. AJNR Am J Neuroradiol. 1990; 11: 869–874.

Henry

Klonaris

. Benefits of cerebral protection during carotid stenting with the PercuSurge GuardWire System: Midterm results. J Endovasc Ther. 2002; 9: 1–13.

10.

Adami

Scuro

Spinamano

. Use of the Parodi Anti Embolism System in carotid stenting: Italian trial results. J Endovasc Ther. 2002; 9: 147–154.

11.

Reimers

Schluter

Castriota

. Routine use of cerebral protection during carotid artery stenting: Results of a multicenter registry of 753 patients. Am J Med. 2004; 116: 217–222.

12.

Cremonesi

Manetti

Setacci

. Protected carotid stenting. Clinical advantages and complications of embolic protection devices in 442 consecutive patients. Stroke. 2003; 34: 1936–1943.

13.

Ohki

Veith

Grenell

. Initial experience with cerebral protection devices to prevent embolization during carotid artery stenting. J Vasc Surg. 2002; 36: 1175–1185.

14.

Shaw

Menard

Eisenhauer

. Approaches to difficult filter retrieval in carotid stenting. Catheter Cardiovasc Intervent. 2005; 64: 18–22.

15.

Wilentz

Chati

Krafft

. Retinal embolization during carotid angioplasty and stenting: Mechanisms and role of cerebral protection systems. Catheter Cardiovasc Intervent. 2002; 56: 320–327.

16.

Wholey

. The history and current status of endovascular management for the extracranial carotid and supra-aortic vessels. J Endovasc Ther. 2004; 11(suppl II): II-43–II-61.

17.

Ohki

Veith

. Critical analysis of distal protection devices. Semin Vasc Surg. 2003; 16: 317–325.

18.

Al-Mubarak

Colombo

Gaines

. Multicenter evaluation of carotid artery stenting with a filter protection system. J Am Coll Cardiol. 2002; 39: 841–846.

19.

Bosiers

Peeters

Verbist

. Belgian experience with FilterWire EX in the prevention of embolic events during carotid stenting. J Endovasc Ther. 2003; 10: 695–701.