Proximal occlusion versus distal filter for cerebral protection during carotid stenting: updated meta-analysis of randomised and observational MRI studies.
OBJECTIVE
Proximal occlusion (PO) and distal filter (DF) serve for cerebral embolic protection during carotid artery stenting (CAS). New cerebral lesions at diffusion-weighted magnetic resonance imaging (DW-MRI) represent a surrogate endpoint for embolisation, though their clinical impact is controversial. We performed a meta-analysis of randomised and observational DW-MRI studies comparing PO and DF during CAS.


RESULTS
We searched electronic scientific databases. The primary endpoint was the incidence of new cerebral lesions at DW-MRI; secondary endpoints were the incidence of new ipsilateral and new contralateral cerebral lesions at DW-MRI and death/cerebrovascular events (CVE). A total of 392 patients (seven studies) received CAS. At DW-MRI after 48 hours 178 patients (48.3%) presented new cerebral lesions. The use of PO versus DF reduced neither the risk of new cerebral lesions (OR [95% confidence interval] 0.65 [0.28-1.52], p=0.32) nor the risk of death/CVE (0.59 [0.22-1.60], p=0.30). Diabetes, baseline stenosis and symptoms significantly modified the risk estimates for new cerebral lesions.


CONCLUSIONS
In this meta-analysis, one half of patients receiving protected CAS developed new embolic cerebral lesions at DW-MRI, although the overwhelming majority were asymptomatic. Cerebral protection with PO versus DF neither reduced cerebral embolisation nor impacted on clinical outcomes.
Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.
Salvatore
S
Cassese
Gjin
G
Ndrepepa
Lamin A
LA
King
Mateja
M
Nerad
Heribert
H
Schunkert
Adnan
A
Kastrati
Ilka
I
Ott
Massimiliano
M
Fusaro
D000368:Aged; D017130:Angioplasty / Q000379:methods; D016893:Carotid Stenosis / Q000453:epidemiology* / Q000601:surgery*; D016208:Databases, Factual; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods; D057505:Embolic Protection Devices; D005260:Female; D006801:Humans; D015994:Incidence; D020766:Intracranial Embolism / Q000453:epidemiology*; D008297:Male; D064887:Observational Studies as Topic; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D015607:Stents / Q000009:adverse effects; D016896:Treatment Outcome