The results of a simplified technique for safe carotid stenting in the elderly

The purpose of this study was to report the preliminary experience of a modified transcervical carotid angioplasty and stenting (CAS) technique with filter protection and flow reversal only during filter placement in patients unsuitable for transfemoral CAS and at high risk for carotid endarterectomy (CEA).

Twenty-five of 132 patients, aged 75 to 86 years old, with severe carotid stenosis had been selected. Eighteen patients had transient ischemic attacks (TIAs) in the last month and seven patients were asymptomatic. Patients with limited life expectancy were not included. The common carotid artery (CCA) was mobilized and cannulated. The flow in the internal carotid artery (ICA) was reversed by occluding the proximal CCA and connecting the introducing sheath to a blood transfusion bag positioned close to the floor, instead of returning it directly to the venous system. This produced retrograde flow in the ICA in all patients as a result of greater pressure gradient. The carotid filter was inserted to the distal ICA under retrograde flow and then antegrade flow was resumed and CAS was performed. All patients were autotransfused except for four patients who had severe renal insufficiency to avoid readministration of contrast media.

All procedures were successful except in one patient converted to open endarterectomy because of CCA dissection (technical success rate 97.5%) and one patient who had a TIA involving the right hand 10 hours after CAS and recovered completely after 3 hours (event rate 2.5%). Reversed flow was visualized with intraoperative angiography in the ICA in all patients. Twenty-two patients were discharged the next morning and three (12%) on the following day because of hypotension. The duration of reversed flow was 1 to 4 minutes (mean, 1.5 minutes), the amount of blood collected was 100 to 400 mL (mean, 250 mL), and none of these patients had any hemodynamic disturbance during the procedure. Creatinine levels showed no increase postoperatively in either patient. The patients were followed-up clinically and with color Duplex scan for 3 to 24 months, so far, and they are free of symptoms or significant restenosis.

The results of this preliminary study indicate that the transcervical approach with flow reversal during the insertion of the protecting filter allows CAS with minimal interruption of cerebral circulation and is simple and safe in patients unsuitable for CEA and transfemoral CAS for anatomic reasons. Further research with randomization and with pre-procedure and post-procedure diffusion-weighted magnetic resonance imaging (DW-MRI) is required in order to expand the indications of this method.