REVIEW  PROXIMAL PROTECTION IN CAROTID ARTERY STENTING: WHO’S AFRAID OF IT? Free access

Minerva Cardiology and Angiology 2022 December;70(6):751-64

DOI: 10.23736/S2724-5683.22.06246-9

Copyright © 2022 EDIZIONI MINERVA MEDICA

language: English

Intolerance to occlusion during carotid artery stenting with proximal protection: causes, mechanisms, treatment and prevention

Piero MONTORSI ^{1, 2} ✉, Elisabetta MANCINI ², Stefano GALLI ², Giovanni TERUZZI ², Luigi CAPUTI ³, Cristina FERRARI ², Sarah TROIANO ², Paolo OLIVARES ², Paolo M. RAVAGNANI ², Daniela TRABATTONI ²

¹ Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; ² Centro Cardiologico Monzino IRCCS, Milan, Italy; ³ Division of Neurology, ASST Crema, Crema, Cremona, Italy

Periprocedural cerebral microembolization is the most important complication of carotid artery stenting. Among several variables that play a role to reduce this risk, brain protection (proximal vs. distal) plays a pivot role. Data are accumulating in favor of a better performance of proximal vs. distal especially in symptomatic patients and high-risk carotid plaques. A prerequisite for the technique to be safe and effective is the presence of a valid intracranial collateral circulation to compensate for the target vessel hemisphere avoiding patient intolerance. This complication may occur either soon after the common carotid balloon occlusion or slowly developing during the procedure peaking at the stent post-dilation step. While Willis’ circle anatomic variants are the most frequent cause of acute intolerance, a mix of anatomic, hemodynamic and patient cerebral condition play a role for the late developing form. Prevention is the best treatment of intolerance through a pre- and procedural imaging with different techniques (CT angiography, NMR angiography, transcranial Doppler assessment, digital subtraction angiography and back pressure monitoring).

KEY WORDS: Circle of Willis; Ultrasonography, Doppler, transcranial; Cerebral angiography