Why go through all this research to solve the problems of stenting when the easiest solution would be: determine if the Circle of Willis is complete; if so close up the offending artery instead of stenting it. Does no one in stroke THINK AT ALL?
Problems to consider:
You might want to ask your doctor about this?
New ischemic brain lesions on diffusion-weighted MRI after treatment were found in 51% of cases after stenting. Link here
1. Talk to your doctor about why you would want to put inflexible metal stents in flexible arteries.
2. You might want to prevent stent placement complications per European Society of Cardiology
A - Minor complications
Carotid artery spasm
Sustained hypotension / bradycardia
Carotid artery dissection
Contrast encephalopathy (very rare)
Minor embolic neurological events (TIAs)
B - Major complications
Major embolic stroke
Intracranial hemorrhage
Hyperperfusion syndrome
Carotid perforation (very rare)
Acute stent thrombosis (very rare)
Complications at the site of the vascular access
Article Commentary: “Impact of Carotid Stent Design on Embolic Filter Debris Load During Carotid Artery Stenting”
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are commonly used for severe carotid stenosis, particularly in patients with stroke referable to the side of stenosis. Customary use of CAS as an alternative to CEA has been observed in high-risk patients due to substantial comorbidities or challenging neck and carotid anatomy. While CAS offers proven benefits, it also entails the risk of cerebral embolism, with clinic data suggesting neurological complications in 2-8% of cases, while post-procedural MRI findings indicate embolic strokes in about 60% of patients. The introduction of new-generation micromesh stents (MMS) aimed to reduce embolization resulting from plaque manipulation, although comparative studies with other stent types are lacking. In this study, the authors aimed to assess the quality of captured embolic material using different stent designs during CAS in asymptomatic patients.
Squizzato et al. conducted a single-center study involving patients (n=481) with asymptomatic carotid stenosis who underwent carotid artery stenting (CAS) between 2010 and 2022. Asymptomatic carotid stenosis was defined as the absence of any neurological symptoms or strokes related to the ipsilateral stenosis within 180 days before the procedure. Patients were included if a filter was used for embolic protection. In contrast, those with other modes of embolic protection, treatment for in-stent restenosis, or specific high-risk anatomical features (circumferential aortic arch thrombus, excessive carotid tortuosity, or carotid floating thrombus) were excluded. Stenosis severity was assessed using CT angiography and carotid duplex ultrasound based on NASCET criteria. Patients were categorized into three groups based on the stent type: open-cell stents (OCS), closed-cell stents (CCS), and micromesh stents (MMS), and were managed with aspirin and statin. Stent selection was at the treating physician's discretion, and all patients were administered a filter for embolic protection, usually positioned in the distal extracranial internal carotid artery (ICA). Before the procedure, patients were given aspirin (80mg to 300mg daily) for at least three days, followed by a 300mg clopidogrel loading dose the day of the procedure, and dual antiplatelet therapy (clopidogrel 75mg and aspirin 100-160mg) for at least one month. The study's primary endpoint was the embolic filter debris (EFD) load, while the secondary endpoints included 30-day major stroke and death.
In this study of 481 patients undergoing carotid artery stenting, the distribution of embolic protection devices (EPDs) was as follows: 35% used an OCS, 14% a CCS, and 50% an MMS. The mean plaque length was 148 mm, and a plaque length >15mm was present in 183 (38%) cases (OCS, 38%; CCS, 32%; MMS, 39%; P=0.547). While non-significant, there was a trend with the use of CCS or MMS in cases of hypoecogenicity and OCS or MMS in cases of severe carotid angulation or tortuosity. For the primary endpoint of embolic filter debris (EFD) load, patients who underwent stenting with MMS were more likely to be free from EDP (OCS, 29.8%; CCS,13.2%; MMS, 40.9%; P<0.001) and had lower EFD load (OCS, 9.114.5; CCS,7.914.0; MMS 5.09.1; P<0.001). These differences persisted even when accounting for plaque characteristics (hypoecogenicity and plaque length >15mm) and preoperative cerebral ischemic strokes. None of the secondary endpoints within 30 days were statistically significant. One death (0.6%) occurred in the open-cell stent (OCS) group, with no instances in the closed-cell stent (CCS) or mesh-covered stent (MMS) groups. There was one major ischemic stroke (0.6%) in the OCS group and a total of eight minor stroke events, comprising three cases (1.7%) in the OCS group, one case (1.4%) in the CCS group, and four cases (1.6%) in the MMS group. The multivariate linear regression showed that MMS use was associated with lower EFD load (P=0.038).
This study found that using a multi-layered mesh stent (MMS) resulted in a lower rate of embolization and embolic filter debris compared to other stenting methods like open-cell stents (OCS) and closed-cell stents (CCS). Notably, this effect was independent of plaque characteristics, filter type, or dwell time. These findings are crucial given the occurrence of embolic strokes, even with the use of embolic-protecting devices following the procedure, which can be implied to be due to the manipulation of plaque and its features, such as its soft component, ulceration, and degree of calcification, contribute to these post-procedural complications. The plaque protrusion through the stent struts is one of the significant causes of embolism, and the design of the MMS with its double layer would theoretically decrease the rate of embolic events and embolic filter debris. Interestingly, the study revealed that 13% of patients had pre-operative ipsilateral silent ischemic infarcts, with a higher incidence observed in the MMS group, which could be explained by the fact that it was the most common stent type used in carotid stenosis with the highest risk features. However, neither the pre-operative ipsilateral stroke nor the preference for a specific stent design based on plaque characteristics showed statistical significance. Despite the low rate of minor strokes, the MMS group was the second for this complication, leading to the question of whether having less EFD load translates into less clinically significant embolic events or if, as mentioned earlier, this group is as likely as the other groups to have similar event rates despite its design advantages due to its higher risk vessels that in which providers tend to use MMS. As shown in this article, the lack of randomization of the subjects highlights the absence of standardized protocols for selecting stent designs based on plaque characteristics, which might introduce bias in the assignment process. Nonetheless, given the retrospective nature of the study, it was inevitable to avoid this bias altogether. In conclusion, the study underscores the importance of carotid stent design and its application in plaques with a high risk of perioperative embolization.
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