Related Experiment Video
Updated: May 10, 2026
A Modified Model Preparation for Middle Cerebral Artery Occlusion Reperfusion
Published on: May 31, 2024
Unprotected carotid artery stenting in modern practice
Jay Giri1, Robert W Yeh, Kevin F Kennedy
1Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
Insights
Embolic protection devices (EPDs) did not show a significant benefit in reducing stroke or death during elective carotid artery stenting (CAS). Patients undergoing unprotected CAS had higher pre-procedure risk factors, but filter EPDs did not alter outcomes in this study.
Area of Science:
- Cardiovascular Interventions
- Neurology
- Medical Devices
Background:
- Embolic protection devices (EPDs) are recommended to reduce peri-procedural strokes during carotid artery stenting (CAS).
- Medicare mandates EPD use for reimbursement, yet clinical outcome data remain mixed.
- Unprotected CAS is performed in a small but notable percentage of procedures.
Purpose of the Study:
- To characterize patients undergoing unprotected CAS.
- To assess the effectiveness of distal filter EPDs (F-EPDs) in elective CAS procedures.
- To evaluate the association between F-EPD use and major adverse events (MAE).
Main Methods:
- Analysis of patients from the CARE Registry® undergoing CAS (May 2005 - January 2012).
- Comparison of outcomes between patients who received F-EPDs versus those who did not (No-EPD).
- Unadjusted and 1:3 propensity-matched analyses to assess the composite of in-hospital death or stroke (MAE).
Main Results:
- 4.4% of CAS cases were performed without EPD.
- Patients in the No-EPD group had significantly higher pre-procedure neurologic risk factors.
- No significant difference in MAE was observed between No-EPD and F-EPD groups in elective cases, both unadjusted and propensity-matched.
Conclusions:
- Patients undergoing unprotected CAS often present with substantial pre-procedure neurologic risks.
- Filter EPDs did not demonstrate a significant benefit or harm in elective CAS patients in this analysis.
- Further research may be needed to clarify the role of EPDs in specific patient subgroups.
Background & Purpose:
Embolic protection devices (EPD) may provide a mechanism to reduce peri-procedural strokes. They are advocated by consensus guidelines and mandated for Medicare reimbursement. However, outcomes data remain mixed. We aimed to characterize the population of patients undergoing unprotected carotid artery stenting (CAS) and assess the utility of distal filter EPD (F-EPD) in elective CAS.
Methods:
We analyzed patients enrolled in the CARE Registry® undergoing CAS between May, 2005 and January, 2012. We assessed the relationship between distal F-EPD use versus no use (No-EPD) and the composite of in-hospital death or stroke (MAE) in unadjusted and 1:3 propensity-matched analyses.
Results:
Embolic protection was not attempted in a total of 579 out of 13,263 cases performed (4.4%). Patients in the No-EPD group had worse preprocedure neurologic risk factors including higher rates of acute evolving stroke, prior TIA/stroke, symptomatic lesion status, spontaneous carotid artery dissection, and use of general anesthesia intraprocedurally (all Standardized Differences{sd} >10). After exclusion of nonelective cases there was no significant difference in MAE between the No-EPD and F-EPD groups (1.6% vs. 2.3%, sd = 4.72). Additionally, after propensity matching, rates of MAE did not differ between the No-EPD (n = 355) and F-EPD (n = 1065) groups (1.7% vs. 2.5%, sd = 5.87).
Conclusions:
Patients selected to undergo unprotected CAS in contemporary practice have high rates of adverse preprocedure neurologic risk factors. Our propensity-matched analysis did not demonstrate evidence of significant benefit or harm associated with use of F-EPD in elective CAS patients.
