January 25th, 2012
Heads Up (Lesions Down) on a New Embolic Protection Device for Carotid Arterial Stenting
Richard A. Lange, MD, MBA and L. David Hillis, MD
The current standard of care for individuals undergoing carotid arterial stenting (CAS) entails the use of an embolic protection device (EPD) to minimize the risk for embolic stroke. At present, the only FDA-approved EPD is a filter that is placed distal to the stenosis (i.e., it is advanced across the lesion) before stenting.
In a recently completed randomized trial, a proximal balloon occlusion device provided better cerebral protection during CAS than a distal filter device. Compared with distal filter protection, proximal balloon occlusion resulted in a significant reduction in the incidence of new cerebral ischemic lesions, as assessed by diffusion-weighted MRI (45.2% vs. 87.1%, P=0.001). The rate of major adverse cardiovascular and cerebral events at 30 days did not differ between the two devices, although the study was underpowered to detect such a difference.
The author of an accompanying editorial finds these results “sensible, since in contrast to distal EPDs, proximal EPDs provide embolic protection prior to crossing the target lesion with a guidewire, and should be more efficient at capturing and removing debris since they are not dependent on filter pore size or particle dimensions.”
Sorry, there are no polls available at the moment.
Is this a game changer for you?
In your patients with asymptomatic severe carotid arterial stenosis (>70% diameter narrowing), do you recommend medical therapy, endarterectomy, or stenting?
Would the use of a better EPD change your management strategy?
3 Responses to “Heads Up (Lesions Down) on a New Embolic Protection Device for Carotid Arterial Stenting”
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Is this a relapsing-remitting case, or I have some kind of memory problem ?. Formerly, a similar case was proposed, in the older one the patient having an history of TIA and of radiation therapy in the head & neck region; RT is linked to a very high increase in cardiovascular risk and events, for which I know no preventive measure, although the consideration of ACEIs for the purpose of risk reduction in this frame may have some supporting rationale. For intracraneal carotid stenosis, medical therapy has shown superiority to surgical procedures, but this can’t be extrapolated to carotid stenosis located elsewhere. Most papers in the literature point to an urgent surgical therapy,if the patient is symptomatic, and also some kind of surgery-compatible medical therapy with an stenosis over 70%, but risk factors should not be neglected, and a complete lipid profile, glycemia, and also an OGTT, as for patients not being known diabetics and suffering a cardiovascular event who had an Oral Glucose Tolerance Test performed, one third are discovered being unknown diabetics, other third have an Impaired Glucose Tolerance, and just one third are found having a normal carbohydrate metabolism. Every effort should be done to act on CV risk modifiable factors, such as smoking and hypertension, but probably over 50 % of the risk factors in a patient like this won’t be susceptible of intervention. After a discussion with a vascular surgeon about its feasibility, a minimal medical approach for a patient like this can be Aspirin plus Clopidogrel or Aspirin plus Dipyridamole, and for sure an immediate start of moderate to high dose statins, for example Rosuvastatin, that although not statistically significant, has shown some kind of better effects on plaque and intima thickness reduction over Atorvastatin. Am I wrong ?. Please let me know, doctor.
Competing interests pertaining specifically to this post, comment, or both:
Nay
The debate between CAS and CEA continues, despite results from recent studies such as CREST. The answer to the polled question is certainly not simple – one must take into account factors such as the patient’s age, co-morbidities, whether “optimal medical therapy/best medical therapy” has been prescribed, operator experience, use of embolic protection devices etc. FInally, the decision to pursue one treatment modality over another must involve the patient him/herself, and his/her input about the risks and benefits of an individualized approach. Because the data is still not conclusive, I don’t believe that a physician can categorically endorse one treatment strategy over another, but rather render the “best medical OPINION” based on the studies to date.
Statin,good control blood pressure preferably by ACEI or ARB, an antiplatelet, good glycemic control. What else are required?