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Giannakopoulos T. G. 1, Antonopoulos C. N. 1, Moulakakis K. 1, Sfyroeras G. S. 1, Kakisis J. D. 1, Brountzos E. N. 2, Liapis C. D. 1
1 Department of Vascular Surgery, University of Athens Medical School, “Attikon” University Hospital, Athens, Greece;
2 Second Department of Radiology, University of Athens Medical School, “Attikon” University Hospital, Athens, Greece
The carotid plaque echogenicity has been shown to be a determinant of its embolic potential. Since the introduction of carotid angioplasty and stenting (CAS) intraprocedural cerebral embolization has become even more important. The aim of this study was to review the evidence on incidence and nature of embolic material captured in filter embolic protection devices (EPD) and investigate possible implications on the different aspects of the CAS procedure. A PubMed search for clinical trials/registries published from January 2010 to April 2013 studying embolic phenomena during carotid stenting was conducted. After exclusion of 8 irrelevant studies, 30 publications were included in the analysis. Additionally, relevant literature on available methods for captured EPD analysis was retrieved and reviewed. Twenty-eight studies involving 9990 CAS procedures were identified, data were extracted and included in the analysis. Outcome was assessed by clinical criteria in 13 studies, by magnetic resonance diffusion-weight imaging in 12 studies and by debris analysis in 4. Ultrasound plaque characterization was employed in 1 study, transcranial Doppler microembolic signals counts in 3 studies and Doppler flow changes were studied in 1. The 30-day pooled proportions of stroke reached 2.87% (95%CI=2.34-3.45, P=0.05) and transient ischemic attack was reported with a pooled proportion of 2.27% (95%CI=1.42-3.31, P<0.001). Pooled proportion for the 30-day endpoint of stroke/death was 3.82% (95%CI=3.12-4.59, P<0.01), whereas major adverse events was recorded in 44.18% (95%CI=3.43-5.00, P<0.01) of the patients. No clinical implications related to embolic debris load were detected in this review but certain filter design characteristics were reported to improve outcomes. Moreover, post-procedural magnetic resonance imaging new lesions were associated with embolic phenomena. The pooled 30-day stroke/death rate for CAS in this review approached the suggested from current guidelines documents. Embolic debris captured by EPD has been increasingly studied in the literature but results cannot be compared as methods used to study them are diverse and not reproducible in their majority. Plaque echogenicity is a major determinant of embolic potential but the carotid atheroma is not the sole source of intraprocedural debris. Furthermore, other embolization promoting factors are underlined and an algorithm is suggested for planning a CAS procedure with less clinical, cerebral and peri-interventional implications.