title: Combination of flow reversal and distal filter for cerebral protection during carotid artery stenting.
abstract: BACKGROUND
  Carotid artery stenting (CAS) with distal filter protection allows continuous cerebral perfusion, although it is associated with a greater risk of cerebral ischemic complications than other protection systems. To reduce cerebral ischemic complications, CAS was performed under combined cerebral protection using both flow reversal (FR) and a distal filter.
  
  
  METHODS
  Fifty-six stenoses of 52 patients were treated with CAS using the combined protection of FR and a distal filter, with intermittent occlusion of both the common carotid artery (CCA) and the external carotid artery. The blood flow was reversed into the guiding catheter to the central venous system via an external filter, which collected the debris. Clinical outcomes, the rates of capturing visible debris, and new ischemic signals on diffusion-weighted magnetic resonance imaging (DWI-MRI) were evaluated.
  
  
  RESULTS
  The overall technical success rate was 92.9% (52/56). Successful stent deployment was achieved in 100% (56/56) of the cases. No procedural-related emboli causing a neurologic deficit were observed. In 38.5% (20/52) of the cases, visible debris were captured by only the external filter, and in 17.3% (9/52), visible debris were captured by both external and distal filters. In no case was visible debris noted in only the distal filter. New ischemic signals on DWI-MRI were detected in 9.6% (5/52). The 30-day myocardial infarction, stroke, and death rates were 0%.
  
  
  CONCLUSIONS
  The additional use of a distal filter captures emboli in 17.3% of cases, and because the occlusion is only intermittent, the procedure is potentially applicable even in those who cannot tolerate prolonged balloon occlusion of the CCA.
authors.affiliation: Department of Neurosurgery, Fukuoka Wajiro Hospital Heart & Neuro-Vascular Center, Fukuoka, Japan. Electronic address: keihara@f-wajirohp.jp.
authors.forename: Kei
authors.initials: K
authors.lastname: Harada
authors.affiliation: Department of Neurosurgery, Fukuoka Wajiro Hospital Heart & Neuro-Vascular Center, Fukuoka, Japan.
authors.forename: Kousuke
authors.initials: K
authors.lastname: Kakumoto
authors.affiliation: Department of Neurosurgery, Fukuoka Shinmizumaki Hospital, Fukuoka, Japan.
authors.forename: Jun
authors.initials: J
authors.lastname: Morioka
authors.affiliation: Department of Cardiology, Fukuoka Wajiro Hospital Heart & Neuro-Vascular Center, Fukuoka, Japan.
authors.forename: Tarou
authors.initials: T
authors.lastname: Saito
authors.affiliation: Department of Neurosurgery, Fukuoka Wajiro Hospital Heart & Neuro-Vascular Center, Fukuoka, Japan.
authors.forename: Kouzou
authors.initials: K
authors.lastname: Fukuyama
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation*; D021721:Balloon Occlusion / Q000009:adverse effects; D002545:Brain Ischemia / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D017536:Carotid Artery, Common / Q000000981:diagnostic imaging / Q000503:physiopathology*; D002342:Carotid Artery, External / Q000000981:diagnostic imaging / Q000503:physiopathology*; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D038524:Diffusion Magnetic Resonance Imaging; D057505:Embolic Protection Devices; D005260:Female; D006801:Humans; D020766:Intracranial Embolism / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012039:Regional Blood Flow; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome