Embolization Protection Device Specific Complications During Carotid Angioplasty and Stenting

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Introduction and Objectives:
Embolic protection devices (EPD) using either an internal carotid artery (ICA) filter or balloon occlusion are typically employed during carotid artery stent placement. This study compares the complications encountered using these two EPDs.
Methods:
Retrospective review of patients undergoing CAS using balloon occlusion EPD (PercuSurge GuardWire) or filter EPD (Accunet, AngioGuard, FilterWire). Complications were defined as: Minor stroke: NIH stroke scale <3, Major stroke NIH stroke scale >3. TIA: reversible focal neurologic impairment, Technical: reversible neurologic compromise with EPD deployed, inability to cross lesion, ICA spasm requiring treatment, EPD related factors that prolonged CAS.
Results:
CAS (n=137) was performed in 128 patients, 83% men of mean age 72yrs, with comorbidities included diabetes 36%, coronary artery disease 78%, hypertension 82%, and renal insufficiency 15%. Indication was previous CVA in 12%, TIA in 27%, and asymptomatic >80% stenosis in 61%. Primary lesions were treated in 83%, restenosis in 16% and dissection in 1%. Major stroke rate was 0.8%, total stroke rate was 3%, 30 day stroke and death rate was 4%. Myocardial infarction occurred in 1.6%. There was no difference in stroke and death rate between EPD groups. Technical complications are shown in the table:
(*=p<.05) In 4 Balloon group cases the procedure was aborted (3) or performed without EPD. In two Filter cases the EPD failed to cross the lesion despite unprotected pre-dilatation and forced procedure completion with balloon occlusion.
Conclusions:
During CAS filters may be used preferentially to avoid the 10% incidence of reversible neurologic compromise associated with balloon occlusion except in critically narrowed or tortuous lesions when balloon occlusion may be preferred because of the rare need for unprotected pre-dilatation.