Embolic Protection — Its Role in Carotid, Coronary and Renal Intervention
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Background
Arterial atherosclerosis can affect any organ in the body, and its consequences are devastating and potentially life threatening. Myocardial infarction (MI), stroke and peripheral vascular disease (PVD) are all commonplace throughout both the developed and developing worlds.
Advances both in pharmacotherapy and angioplasty techniques have meant that a fair proportion of this disease burden can be dealt with by percutaneous and nonsurgical options. Coronary angioplasty is an established way of dealing with simple and increasingly complex coronary disease. Carotid and renal stenting are also gaining favor as the preferred treatment options compared to either medical therapy or surgical treatment.
As the use of vascular stenting increases, so the drive to reduce potential complications and improve success rates intensifies. Initially, in smaller caliber vessels, especially with coronary stenting, the main limitation of success was the risk of restenosis. This issue has largely been overcome in the era of drug-eluting stents (DES). As interventionalists take on more challenging cases, the focus has shifted towards improving not only epicardial, but also microvascular flow by preventing downstream embolization from the angioplasty site. Such distal embolization can occur with any vascular intervention. Although embolization from local atheroma has long been recognized as a potential complication in vascular surgery, direct evidence of this phenomenon was also observed during saphenous vein graft (SVG) angioplasty. There is now increasing evidence that similar embolization also occurs during carotid and renal stenting, and in certain native coronary lesions with a high thrombus burden. Innovative new techniques are being pioneered to improve the success rates of endovascular stenting and one of the areas on which clinical emphasis is focused is that of embolic protection.
In this article, we review areas of vascular intervention where distal protection is being used, the types of protection devices available, examine the evidence for their use and discuss future concerns and directions.
Carotid stenting. Carotid endarterectomy (CEA) is a well-recognized and effective treatment for stroke prevention in patients with significant carotid stenosis.1 The standard of care for both symptomatic and asymptomatic carotid artery stenosis has been established by the results of a number of large, prospective randomized trials of medical therapy and CEA namely The North American Symptomatic Carotid Endarterectomy Trial (NASCET),2 the MRC European Carotid Surgery Trial (ECST)2 and the Asymptomatic Carotid Atherosclerosis Study (ACAS).3 These studies demonstrated a significant reduction in ipsilateral stroke at five years with CEA compared to conservative treatment in patients with symptomatic carotid stenosis > 50% or asymptomatic stenosis > 70%.
Carotid artery stenting (CAS) as an alternative to CEA has always been viewed with caution. Carotid atherosclerotic lesions are similar histologically to coronary lesions with a lipid rich core and an overlying fibrous cap.5 The carotid plaque is often friable and the concern with stenting has justifiably, always been the high risk of distal embolization with its potential catastrophic risk of stroke. Studies using transcranial Doppler have demonstrated evidence of distal embolization in every patient treated.6 Advances in techniques and equipment have, however, made carotid stenting a viable alternative to endarterectomy. To date, there has only been one completed prospective multicenter trial comparing endovascular with surgical treatment: the Carotid And Vertebral Transluminal Angioplasty Study (CAVATAS).7 This study reported similar outcomes with CAS and CEA, despite the fact that most of the CAS patients were treated with balloon angioplasty alone, and < 25% of patients underwent stenting. Cerebral protection was not used in any of the cases and furthermore, the surgical outcome in CAVATAS was worse than that reported in the majority of carotid surgery trials. Two other studies comparing CEA with CAS (without embolic protection), however, had to be terminated early due to a worse outcome with the percutaneous approach.
Although no prospective trials of carotid stenting have been performed which randomize patients to embolic protection or unprotected CAS, several case series,10,11 and a large retrospective review of registry data demonstrated that embolic protection significantly reduced the rate of stroke and thromboembolic complications (1.6 versus 5.5%, p < .001).12
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My dad was just diagnosed with an aneurysm behind the kidneys. It is 6 cm. Sisters Hospital in Buffalo, NY will not do the surgery. However, they referred us to Cleveland Clinic for a procedure not approved by the FDA they said. It is called stent-graft. We believe it has been growing for about 10 years as that is when he had his last surgery for an aneurysm in the same area (5.1 cm). It has since cut off the blood supply to one of his kidneys as they found it had atrophied and they believe it will not return to function even after any type of surgery. Can you tell if Cleveland Clinic is the only area we can go to?
Also, they are asking that he be put through a stress test first to get approval (or disapproval) from his heart specialist before going to Cleveland. We don't think this is a good idea under the current circumstances of high blood pressure and the size of the aneurysm. Can you give me some more information??
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