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Home > Press Center > Carotid Stenting Leads to More Microembolic Events

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Emily Kalata
Assistant Director, Communications
312.334.2309

More than 700,000 strokes occur in the United States each year, resulting in major disability and more than 160,000 annual deaths. As the third leading cause of death in the United States, strokes most frequently result from acute ischemia, 20 percent of which are due to atherosclerotic occlusive disease in the carotid artery.

“While carotid endarterectomy (CEA) has been considered the gold standard for the surgical treatment of symptomatic or high-grade carotid occlusive disease, numerous trials now suggest that carotid angioplasty and stenting (CAS) may be just as effective as CEA in the management of specific subsets of high-risk patients,” said Jason T. Lee, MD, assistant professor of surgery in the division of vascular surgery at Stanford University Medical Center in Stanford, Calif. “We need to be careful about selecting the appropriate patients for carotid stenting.”

Dr. Lee and his colleagues found that standard open CEA surgery appears to offer a lower risk of peri-procedural microembolic events detected by diffusion-weighted magnetic resonance imaging (DW-MRI) when compared to CAS using current distal protection technology. Pre- and post-procedure DW-MRI exams were obtained in a non-randomized series of 47 patients undergoing CAS and CEA. The study is published in the August 2007 Journal of the Society of Vascular Surgery.
    
In the study, 27 consecutive CAS procedures were performed safely without any permanent neurologic deficits. However, cerebral microembolic events occurred in more than two-thirds of the procedures despite the uniform use of distal protection. Nineteen of the 27 CAS patients demonstrated evidence of postoperative, acute, cerebral microemboli by DW-MRI. By univariate analysis, performing an arch angiogram prior to CAS was associated with a higher risk of microemboli (median microemboli five vs. none). In the CAS patients who had postoperative emboli, nine were ipsilateral to the index carotid lesion; three were contralateral; and seven were bilateral. This was in distinct contrast to the 20 patients in the study period undergoing CEA, of which none showed postoperative microemboli by DW-MRI.

“The relative safety of percutaneous carotid interventions remains controversial and few studies have used DW-MRI to evaluate their safety,” said Dr. Lee. “To our knowledge, microembolic events within 24 hours following CEA and CAS have not been compared concurrently in a single institution using identical imaging protocols.”

Dr. Lee added that until the long-term significance of these microemboli can be elucidated, procedural selection for carotid lesions should incorporate the differential risk associated with these two differing approaches to procedural-based stroke risk reduction therapy.