Comparison of various cerebral protection devices used for carotid artery stent placement: an in vitro experiment.

PURPOSE To compare the effectiveness of five basic cerebral protection devices designed for carotid angioplasty in an in-vitro bench-top model. MATERIALS AND METHODS Simulation of embolization from carotid angioplasty (n = 180) was performed with polyvinyl alcohol (PVA) particles (Contour; 150-1,000- micro m) in an open flow model simulating the aortic arch with a carotid bifurcation made from elastic silicone tubes. Particles (150-250 micro m [small], 355-500 micro m [medium], 710-1,000 micro m [large]; 5 mg each) were injected separately into the internal carotid artery (ICA) proximal to the placed protection device. Five devices were tested: the Angioguard (AG), Filter Wire EX (EX(A), EX(B)), Trap, Neuroshield (NS), and GuardWire Plus (GW). Particles getting past the protection device or flowing into the external carotid artery (ECA) were caught in a filter at the end of both arteries and their weight was determined. RESULTS For small, medium, and large particles, the lowest weight of emboli in the effluent of the ICA was obtained with the NS (0.28 mg, 0.18 mg, and 0.07 mg, respectively; P <.001 compared to all other devices except the GW for small particles only). The GW had the highest embolization rate into the ECA for all particle sizes. When combining the particle weights for the different protection devices, the NS showed the lowest weight of emboli into the ICA filter (0.53 mg/3.5%; P <.001 compared to all [>1.1 mg/7.0%]). The GW revealed the highest weight of emboli into the ECA (1.2 mg/7.6%; P <.001 compared to all [<0.59 mg/0.09%]). Effectiveness of the EX(B) device was enhanced when circumferentially deployed under direct view (EX(B), 0.39 mg/2.58%; EX(A), 1.18 mg/7.81%; P <.001). CONCLUSIONS In vitro, none of the tested devices or modifications has the ability to prevent embolization completely. An occlusion balloon leads to increased embolization into the ECA. The effectiveness of the EX might be enhanced with design improvements. During this evaluation, the NS was most effective for preventing PVA particle embolization of the three different particle groups within this in-vitro model.

[1]  C. Bladin,et al.  Transcranial Doppler detection of microemboli during percutaneous transluminal coronary angioplasty. , 1998, Stroke.

[2]  J. Martin,et al.  Complications of carotid angioplasty and stenting. , 1998, Neurosurgical focus.

[3]  H. Yonas,et al.  Temporary balloon test occlusion of the internal carotid artery: experience in 500 cases. , 1995, AJNR. American journal of neuroradiology.

[4]  L. A. Gillilan.  The Collateral Circulation of the Human Orbit , 1961 .

[5]  Lippincott Williams Wilkins,et al.  Clinical advisory: carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. , 1994, Stroke.

[6]  P. Teirstein,et al.  Retrieval and analysis of particulate debris after saphenous vein graft intervention. , 1999, Journal of the American College of Cardiology.

[7]  Max Amor,et al.  Angioplasty and Stenting of the Extracranial Carotid Arteries , 1998, Texas Heart Institute journal.

[8]  C. Di Mario,et al.  Cerebral Protection With Filter Devices During Carotid Artery Stenting , 2001, Circulation.

[9]  S. Lavine,et al.  Balloon-protected carotid angioplasty. , 2000, Neurosurgery.

[10]  J. Parodi,et al.  Initial evaluation of carotid angioplasty and stenting with three different cerebral protection devices. , 2000, Journal of vascular surgery.

[11]  V. Hachinski,et al.  The North American Symptomatic Carotid Endarterectomy Trial : surgical results in 1415 patients. , 1999, Stroke.

[12]  A. Casasco,et al.  Percutaneous angioplasty of atherosclerotic and postsurgical stenosis of carotid arteries. , 1987, AJNR. American journal of neuroradiology.

[13]  C. Warlow,et al.  MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis , 1991, The Lancet.

[14]  Edward B. Diethrich,et al.  Stenting in the Carotid Artery: Initial Experience in 110 Patients , 1996, Journal of endovascular surgery : the official journal of the International Society for Endovascular Surgery.

[15]  G. Sicard.  MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or mild (0–29%) carotid stenosis: European Carotid Surgery Trialist' Collaborative Group. Lancet 1991;337:1235-43 , 1992 .

[16]  A M Malek,et al.  Carotid artery stent placement for atherosclerotic disease: rationale, technique, and current status. , 2000, Radiology.

[17]  P. Courtheoux,et al.  New triple coaxial catheter system for carotid angioplasty with cerebral protection. , 1990, AJNR. American journal of neuroradiology.

[18]  L. Guimaraens,et al.  Carotid artery stenosis: treatment with protected balloon angioplasty and stent placement. , 1996, Radiology.

[19]  S. Kownator,et al.  Carotid stenting with cerebral protection: first clinical experience using the PercuSurge GuardWire system. , 1999 .

[20]  U Kaul,et al.  Elective stenting of extracranial carotid arteries. , 1997, The Journal of the Association of Physicians of India.

[21]  F. Veith,et al.  Efficacy of a filter device in the prevention of embolic events during carotid angioplasty and stenting: An ex vivo analysis. , 1999, Journal of vascular surgery.

[22]  M. Brown,et al.  Comparison of hemodynamic cerebral ischemia and microembolic signals detected during carotid endarterectomy and carotid angioplasty. , 1997, Stroke.

[23]  M. Heller,et al.  Comparison and modification of two cerebral protection devices used for carotid angioplasty: in vitro experiment. , 2002, Radiology.

[24]  C. Derdeyn,et al.  Polyvinyl alcohol particle size and suspension characteristics. , 1995, AJNR. American journal of neuroradiology.