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Transcervical carotid stenting with dynamic flow reversal demonstrates embolization rates comparable to carotid endarterectomy

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Abstract
Purpose: To evaluate a series of patients treated electively with carotid endarterectomy (CEA), transfemoral carotid artery stenting with distal filter protection (CASdp), and transcervical carotid stenting with dynamic flow reversal (CASfr) monitored continuously with transcranial Doppler (TCD) during the procedure to detect intraoperative embolization rates. Methods: Thirty-four patients (mean age 67.6 years; 24 men) with significant carotid stenosis underwent successful TCD monitoring during the revascularization procedure (10 CEA, 8 CASdp, and 16 CASfr). Ipsilateral microembolic signals were segregated into 3 phases: preprotection (until internal carotid artery cross-shunted or clamped if no shunt was used, filter deployed, or flow reversal established), protection (until clamp/shunt was removed, filter retrieved, or antegrade flow reestablished), and postprotection (after clamp/shunt or filter removal or restoration of normal flow). Results: CASdp showed higher embolization rates than CEA or CASfr in the preprotection phase (p<0.001). In the protection phase, CASdp was again associated with more embolization compared with CEA and CASfr (p<0.001). In the postprotection phase, no differences between the revascularization therapies were observed. CASfr and CEA did not show significant differences in intraoperative embolization during any of the phases. Conclusion: TCD recordings demonstrated a significant reduction in embolization to the brain during transcervical carotid artery stent placement with the use of dynamic flow reversal compared to transfemoral CAS using distal filters. No significant differences in microembolization could be detected between CEA and CASfr. The observed lower embolization rates and lack of adverse events suggest that transcervical CAS with dynamic flow reversal is a promising technique and may be the preferred method when performing CAS.
Keywords
carotid endarterectomy, carotid artery stenting, embolization, stroke, transcervical stenting, flow reversal, mortality, transcranial Doppler ultrasonography, PROXIMAL BALLOON OCCLUSION, SILENT CEREBRAL-ISCHEMIA, TRANSCRANIAL DOPPLER, FILTER PROTECTION, RANDOMIZED-TRIAL, ANGIOPLASTY, OUTCOMES, NEUROPROTECTION, METAANALYSIS, PREVENTION

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MLA
Plessers, Maarten et al. “Transcervical Carotid Stenting with Dynamic Flow Reversal Demonstrates Embolization Rates Comparable to Carotid Endarterectomy.” JOURNAL OF ENDOVASCULAR THERAPY 23.2 (2016): 249–254. Print.
APA
Plessers, M., Van Herzeele, I., Hemelsoet, D., Patel, N., Chung, E. M., Vingerhoets, G., & Vermassen, F. (2016). Transcervical carotid stenting with dynamic flow reversal demonstrates embolization rates comparable to carotid endarterectomy. JOURNAL OF ENDOVASCULAR THERAPY, 23(2), 249–254.
Chicago author-date
Plessers, Maarten, Isabelle Van Herzeele, Dimitri Hemelsoet, Nikil Patel, Emma ML Chung, Guy Vingerhoets, and Frank Vermassen. 2016. “Transcervical Carotid Stenting with Dynamic Flow Reversal Demonstrates Embolization Rates Comparable to Carotid Endarterectomy.” Journal of Endovascular Therapy 23 (2): 249–254.
Chicago author-date (all authors)
Plessers, Maarten, Isabelle Van Herzeele, Dimitri Hemelsoet, Nikil Patel, Emma ML Chung, Guy Vingerhoets, and Frank Vermassen. 2016. “Transcervical Carotid Stenting with Dynamic Flow Reversal Demonstrates Embolization Rates Comparable to Carotid Endarterectomy.” Journal of Endovascular Therapy 23 (2): 249–254.
Vancouver
1.
Plessers M, Van Herzeele I, Hemelsoet D, Patel N, Chung EM, Vingerhoets G, et al. Transcervical carotid stenting with dynamic flow reversal demonstrates embolization rates comparable to carotid endarterectomy. JOURNAL OF ENDOVASCULAR THERAPY. 2016;23(2):249–54.
IEEE
[1]
M. Plessers et al., “Transcervical carotid stenting with dynamic flow reversal demonstrates embolization rates comparable to carotid endarterectomy,” JOURNAL OF ENDOVASCULAR THERAPY, vol. 23, no. 2, pp. 249–254, 2016.
@article{7246367,
  abstract     = {Purpose: To evaluate a series of patients treated electively with carotid endarterectomy (CEA), transfemoral carotid artery stenting with distal filter protection (CASdp), and transcervical carotid stenting with dynamic flow reversal (CASfr) monitored continuously with transcranial Doppler (TCD) during the procedure to detect intraoperative embolization rates. 
Methods: Thirty-four patients (mean age 67.6 years; 24 men) with significant carotid stenosis underwent successful TCD monitoring during the revascularization procedure (10 CEA, 8 CASdp, and 16 CASfr). Ipsilateral microembolic signals were segregated into 3 phases: preprotection (until internal carotid artery cross-shunted or clamped if no shunt was used, filter deployed, or flow reversal established), protection (until clamp/shunt was removed, filter retrieved, or antegrade flow reestablished), and postprotection (after clamp/shunt or filter removal or restoration of normal flow). 
Results: CASdp showed higher embolization rates than CEA or CASfr in the preprotection phase (p<0.001). In the protection phase, CASdp was again associated with more embolization compared with CEA and CASfr (p<0.001). In the postprotection phase, no differences between the revascularization therapies were observed. CASfr and CEA did not show significant differences in intraoperative embolization during any of the phases. 
Conclusion: TCD recordings demonstrated a significant reduction in embolization to the brain during transcervical carotid artery stent placement with the use of dynamic flow reversal compared to transfemoral CAS using distal filters. No significant differences in microembolization could be detected between CEA and CASfr. The observed lower embolization rates and lack of adverse events suggest that transcervical CAS with dynamic flow reversal is a promising technique and may be the preferred method when performing CAS.},
  author       = {Plessers, Maarten and Van Herzeele, Isabelle and Hemelsoet, Dimitri and Patel, Nikil and Chung, Emma ML and Vingerhoets, Guy and Vermassen, Frank},
  issn         = {1526-6028},
  journal      = {JOURNAL OF ENDOVASCULAR THERAPY},
  keywords     = {carotid endarterectomy,carotid artery stenting,embolization,stroke,transcervical stenting,flow reversal,mortality,transcranial Doppler ultrasonography,PROXIMAL BALLOON OCCLUSION,SILENT CEREBRAL-ISCHEMIA,TRANSCRANIAL DOPPLER,FILTER PROTECTION,RANDOMIZED-TRIAL,ANGIOPLASTY,OUTCOMES,NEUROPROTECTION,METAANALYSIS,PREVENTION},
  language     = {eng},
  number       = {2},
  pages        = {249--254},
  title        = {Transcervical carotid stenting with dynamic flow reversal demonstrates embolization rates comparable to carotid endarterectomy},
  url          = {http://dx.doi.org/10.1177/1526602815626561},
  volume       = {23},
  year         = {2016},
}

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