title: Microembolization during carotid artery stenting in patients with high-risk, lipid-rich plaque. A randomized trial of proximal versus distal cerebral protection.
abstract: OBJECTIVE
  The goal of this study was to compare the rate of cerebral microembolization during carotid artery stenting (CAS) with proximal versus distal cerebral protection in patients with high-risk, lipid-rich plaque.
  
  
  BACKGROUND
  Cerebral protection with filters partially reduces the cerebral embolization rate during CAS. Proximal protection has been introduced to further decrease embolization risk.
  
  
  METHODS
  Fifty-three consecutive patients with carotid artery stenosis and lipid-rich plaque were randomized to undergo CAS with proximal protection (MO.MA system, n = 26) or distal protection with a filter (FilterWire EZ, n = 27). Microembolic signals (MES) were assessed by using transcranial Doppler during: 1) lesion wiring; 2) pre-dilation; 3) stent crossing; 4) stent deployment; 5) stent dilation; and 6) device retrieval/deflation. Diffusion-weighted magnetic resonance imaging was conducted before CAS, after 48 h, and after 30 days.
  
  
  RESULTS
  Patients in the MO.MA group had higher percentage diameter stenosis (89 ± 6% vs. 86 ± 5%, p = 0.027) and rate of ulcerated plaque (35% vs. 7.4%; p = 0.019). Compared with use of the FilterWire EZ, MO.MA significantly reduced mean MES counts (p < 0.0001) during lesion crossing (mean 18 [interquartile range (IQR): 11 to 30] vs. 2 [IQR: 0 to 4]), stent crossing (23 [IQR: 11 to 34] vs. 0 [IQR: 0 to 1]), stent deployment (30 [IQR: 9 to 35] vs. 0 [IQR: 0 to 1]), stent dilation (16 [IQR: 8 to 30] vs. 0 [IQR: 0 to 1]), and total MES (93 [IQR: 59 to 136] vs. 16 [IQR: 7 to 36]). The number of patients with MES was higher with the FilterWire EZ versus MO.MA in phases 3 to 5 (100% vs. 27%; p < 0.0001). By multivariate analysis, the type of brain protection was the only independent predictor of total MES number. No significant difference was found in the number of patients with new post-CAS embolic lesion in the MO.MA group (2 of 14, 14%) as compared with the FilterWire EZ group (9 of 21, 42.8%).
  
  
  CONCLUSIONS
  In patients with high-risk, lipid-rich plaque undergoing CAS, MO.MA led to significantly lower microembolization as assessed by using MES counts.
authors: Department of Cardiovascular Sciences, University of Milan, Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, Italy. piero.montorsi@unimi.it
authors: Piero
authors: P
authors: Montorsi
authors: Luigi
authors: L
authors: Caputi
authors: Stefano
authors: S
authors: Galli
authors: Elisa
authors: E
authors: Ciceri
authors: Giovanni
authors: G
authors: Ballerini
authors: Marco
authors: M
authors: Agrifoglio
authors: Paolo
authors: P
authors: Ravagnani
authors: Daniela
authors: D
authors: Trabattoni
authors: Gianluca
authors: G
authors: Pontone
authors: Franco
authors: F
authors: Fabbiocchi
authors: Alessandro
authors: A
authors: Loaldi
authors: Eugenio
authors: E
authors: Parati
authors: Daniele
authors: D
authors: Andreini
authors: Fabrizio
authors: F
authors: Veglia
authors: Antonio L
authors: AL
authors: Bartorelli
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000601:surgery*; D002404:Catheterization / Q000295:instrumentation* / Q000379:methods*; D003251:Constriction, Pathologic; D017023:Coronary Angiography / Q000379:methods; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods; D005260:Female; D006801:Humans; D020766:Intracranial Embolism / Q000473:pathology; D008055:Lipids / Q000737:chemistry*; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D012306:Risk; D015607:Stents; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler / Q000379:methods
chemical_list: D008055:Lipids