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Published on: May 14, 2013
Protection filter-related events in extracranial carotid artery stenting: a single-center experience
Bae Ju Kwon1, Moon Hee Han, Hyun-Seung Kang
1Department of Radiology, Seoul National University College of Medicine, 28 Yongon-Dong, Seoul 110-744, Korea.
Insights
Carotid artery stenting (CAS) with embolus protection filters is effective, but can cause technical issues like filter wedging or retrieval failure. Awareness of these complications and rescue techniques is crucial for successful CAS procedures.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Neurosurgery
Background:
- Carotid artery stenting (CAS) is a common procedure for treating extracranial atherosclerotic carotid stenosis.
- Embolus protection filters are frequently used during CAS to minimize the risk of embolic events.
- Complications associated with filter use can impact procedural success and patient outcomes.
Purpose of the Study:
- To detail the complications encountered during CAS when using embolus protection filters.
- To describe the rescue procedures employed to manage filter-related events.
- To evaluate the neurological outcomes following CAS with filter protection.
Main Methods:
- A retrospective review of 77 CAS procedures in 72 patients with carotid stenosis was conducted.
- Procedures utilized embolus protection filters.
- Filter-related events, rescue maneuvers, and neurological outcomes were assessed via angiograms and patient records.
Main Results:
- CAS with filter protection achieved a 99% success rate, with a low 30-day rate of minor stroke (1.3%) and mortality (1.3%).
- Filter-related complications included flow impairment (7.8%), filter wedging (5.2%), vasospasm (9.1%), and retrieval difficulties (3.9% to 2.6%).
- All complications were successfully managed with specific rescue techniques, and neurological events were infrequent.
Conclusions:
- Filter use during CAS can lead to various technical and angiographic events.
- Severe stenosis and tortuous anatomy may increase the risk of filter entrapment or retrieval failure.
- Awareness of preventive and rescue strategies is essential, and alternative protection methods or surgical interventions should be considered.
Purpose:
To report the complications, rescue procedures, and consequences related to the use of an embolus protection filter during carotid artery stenting (CAS).
Methods:
A retrospective review was undertaken of 72 patients (58 men; mean age 70.0+/-8.2 years, range 56-87) with extracranial atherosclerotic carotid stenosis who underwent 77 CAS procedures under filter protection. Filter-related events and rescue procedures according to each procedural step were retrospectively evaluated on CAS angiograms. In addition, neurological events and outcomes were also assessed.
Results:
CAS using a filter was successful in 99% of cases, and the overall rate of minor stroke (n=1), major stroke (0), or mortality (n=1) was 2.6% at 30 days. Filter placement was successful in all cases. However, arterial tortuosity made it difficult for a filter to pass through the stenosis in 1 case; this was overcome with an additional supportive wire (0.018-inch). Filter-related events were flow impairment in 6 (7.8%), filter wedging in the catheter tip in 4 (5.2%), vasospasm >50% narrowing in 7 (9.1%), filling defects within the filter membrane in 5 (6.5%), retrieval failure with the provided retriever in 3 (3.9%), and insecure retrieval without filter collapse in 2 (2.6%). Flow impairment caused drowsy mentality and impaired verbal response in 4, which resolved after prompt filter retrieval. All the cases of filter wedging were resolved with a catheter pulled down into the stented segment to separate the filter element from the catheter tip. Significant vasospasm and filling defects were spontaneously resolved in all cases after filter retrieval. Inability to pass a retriever catheter through a stent was overcome with curved 5-F catheter manipulation in all 3 cases.
Conclusion:
The use of a filter during CAS may induce various angiographic or technical events at each step. For a severely stenotic and tortuous carotid lesion with difficult access, a filter may become trapped or irretrievable during flow arrest. Physicians should be aware of the preventive and rescue maneuvers to counter filter-related events, perhaps even considering another type of protection mechanism or carotid endarterectomy.
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