Invited commentary

Myers, Mark C.; Powell, Richard J.

doi:10.1016/j.jvs.2005.07.037

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Volume 42, Issue 5 , Page 853, November 2005

Invited commentary

Lebanon, NH

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Using diffusion-weighted magnetic resonance imaging (DWI), Hammer et al have demonstrated an alarming rate (40%) of new microinfarcts after filter-protected carotid artery stenting (CAS). These data support previous studies that have demonstrated new microinfarcts in 20% to 43% of patients after CAS.¹, ² They are to be commended on their overall results: there were only two (4%) minor strokes that resolved completely, no myocardial infarctions, and no deaths. The pattern of these cerebral infarcts suggests that they are not due to failure of the embolic protection device. Ipsilateral DWI infarcts occurred with equal frequency in cases with and without visible debris captured in the filter. More importantly, the DWI lesions frequently involved the contralateral cerebral hemisphere, thus suggesting that many occurred before cannulation of the target carotid artery. The occurrence of these DWI lesions seems, on the basis of Hammer and associates’ analysis, to correlate with difficult arch anatomy, supra-aortic carotid torutuosity, and the performance of contralateral brachiocephalic selective catheterization. Thankfully, most of these lesions seem clinically silent, but this would be better evaluated with formal neuropsychiatric testing. These results argue against routine contraleral diagnostic arteriography as part of a CAS procedure, especially because one of the two strokes did occur in the contralateral occipital lobe. In our center, like many, we are careful to minimize manipulations in the aortic arch and attempt to cannulate only the target carotid artery during CAS. Proper patient selection and technical skill will be critical in decreasing CAS neurologic event rates to those seen with carotid endarterectomy, especially in older patient populations, in which CAS stroke and death rates have exceeded 12%.³ We use computed tomographic angiography to screen patients for difficult arch anatomy, evaluate aortic arch plaque burden, and evaluate the carotid lesion length and calcification. We have used this information to exclude some patients from further consideration for CAS on the basis of anatomic concerns. This study by Hammer et al supports the concepts that minimal, focused catheter manipulation within the aortic arch and careful patient selection based on evaluation of aortic arch/carotid anatomy will limit the incidence of neurologic events during CAS.

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References

Schluter M , Tubler T , Steffens JC , Mathey DG , Schofer J . Focal ischemia of the brain after neuroprotected carotid artery stenting . J Am Coll Cardiol . 2003;42:1007–1013

Flach HZ , Ouhlous M , Hendriks JM , et al. Cerebral ischemia after carotid intervention . J Endovasc Ther . 2004;11:251–257

Hobson RW , Howard VJ , Roubin GS , et al. Carotid artery stenting is associated with increased complications in octogenarians (30-day stroke and death rates in the CREST lead-in phase) . J Vasc Surg . 2004;40:1106–1111