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Reduction of Post-Procedure Microemboli Following Retrospective Quality Assessment and Practice Improvement Measures for Carotid Angioplasty and Stenting

Maureen M. Tedesco, Jason T. Lee, Janice J. Yeung, Barton Lane, Wei Zhou, Ronald L. Dalman.
Stanford University Medical Center, Stanford, Calif.

OBJECTIVES: We have previously demonstrated a 70% incidence of microemboli on diffusion weighted magnetic resonance imaging (DW-MRI) following carotid angioplasty and stenting (CAS). The purpose of this study is to compare the incidence of microemboli in two distinct time periods when procedural modifications were implemented into a CAS program.

METHODS: Following a retrospective quality review of our CAS cohort (n=27) from November 2004 through April 2006 (Period 1), we enrolled patients (n=22) from May 2006 through February 2008 (Period 2) undergoing CAS into a prospective cohort that included obtaining pre- and post-procedure DW-MRI exams. Procedural modifications during Period 2 included the preferential use of closed-cell systems (59%), early heparinazation, and elimination of performing a routine arch angiogram. The hospital records of these 49 patients were reviewed; symptoms, co-morbidities, lesion characteristics, peri-procedural information, and postoperative outcomes were collected. The incidence and location of acute, post-procedural microemboli were determined using DW-MRIs.

RESULTS: Twenty (74%) CAS patients from Period 1 and eight (36%) patients from Period 2 demonstrated acute microemboli on post-procedural DW-MRI (p=.02). The mean number of microemboli in Period 1 was 4.1±5.3 vs. 1.5±2.7 during Period 2 (p=.04). Three of the 27 patients (11%) during Period 1 experienced temporary neurologic changes that resolved within 36 hours. None of the patients during Period 2 exhibited any neurologic changes. There were no differences between the two groups with respect to demographics, comorbidities, and presenting symptoms. Period 2 patients when compared to Period 1 had more technically challenging anatomy with more calcified lesions (68% vs. 27%), longer lesions (15.9 mm vs. 8.2 mm), and higher incidence of ulceration (55% vs. 27%) (all p<.04).

CONCLUSIONS: Despite successful performance of 49 consecutive CAS procedures without permanent neurologic sequelae, significant reductions in peri-procedural embolic events as identified via DW-MRI lesions may be achieved through implementation of quality improvement measures identified through continuous outcome analysis. The long term neurologic benefits associated with reduced sub-clinical neurologic events remains to be determined.