title: Proximal versus distal embolic protection for carotid artery stenting: a national cardiovascular data registry analysis.
abstract: OBJECTIVE
  The aim of this study was to compare the stroke/death rates between proximal embolic protection devices (P-EPDs) and distal filter embolic protection devices (F-EPDs) in elective carotid artery stenting (CAS).
  
  
  BACKGROUND
  P-EPDs have theoretical advantages that may make them superior to F-EPDs for stroke prevention during CAS.
  
  
  METHODS
  We examined 10,246 consecutive elective CAS procedures performed with embolic protection in the NCDR CARE registry between January 2009 and March 2013. We analyzed crude and propensity-matched rates of in-hospital combined death/stroke in patients treated with P-EPDs versus F-EPDs. Secondary analyses included 30-day adverse event rates and stroke rates by the involved cerebrovascular territory.
  
  
  RESULTS
  P-EPDs were used in 590 of 10,246 cases (5.8%). Patients treated with P-EPDs had higher rates of symptomatic lesion status (46.8% vs. 39.7%, p<0.001), atrial fibrillation/flutter (16.1% vs. 13.0%, p=0.03), and history of a neurological event (51.2% vs. 46.6%, p=0.03). In unadjusted and propensity-matched analyses, differences in in-hospital stroke/death between P-EPD and F-EPD cohorts were nonsignificant (1.5% vs. 2.4%, p=0.16 and 1.6% vs. 2.0%, p=0.56, respectively). For patients with available data (n=7,693, 75.1%), 30-day adverse events rates were similar for P-EPDs and F-EPDs before (2.5% vs. 4.2%, p=0.07) and after (2.7% vs. 4.0%, p=0.22) propensity matching.
  
  
  CONCLUSIONS
  Use of a P-EPD during CAS was associated with low rates of in-hospital stroke/death similar to those with an F-EPD in the first comparative effectiveness study of the devices. An adequately powered randomized trial comparing clinical outcomes between these devices is unlikely to be feasible.
authors.affiliation: Cardiovascular Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. Electronic address: Giri.jay@gmail.com.
authors.forename: Jay
authors.initials: J
authors.lastname: Giri
authors.affiliation: University Hospitals Harrington Heart and Vascular Institute and Case Western Reserve University School of Medicine, Cleveland, Ohio.
authors.forename: Sahil A
authors.initials: SA
authors.lastname: Parikh
authors.affiliation: St. Luke's Mid-America Heart Institute, University of Missouri - Kansas City, Kansas City, Missouri.
authors.forename: Kevin F
authors.initials: KF
authors.lastname: Kennedy
authors.affiliation: The Institute for Heart, Vascular, & Stroke Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Ido
authors.initials: I
authors.lastname: Weinberg
authors.affiliation: The Institute for Heart, Vascular, & Stroke Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Cameron
authors.initials: C
authors.lastname: Donaldson
authors.affiliation: Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
authors.forename: Beau M
authors.initials: BM
authors.lastname: Hawkins
authors.affiliation: Cardiovascular Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: McCormick
authors.affiliation: Division of Vascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Jackson
authors.affiliation: Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado.
authors.forename: Ehrin J
authors.initials: EJ
authors.lastname: Armstrong
authors.affiliation: Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Preethi
authors.initials: P
authors.lastname: Ramchand
authors.affiliation: John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: White
authors.affiliation: The Institute for Heart, Vascular, & Stroke Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Jaff
authors.affiliation: The Institute for Heart, Vascular, & Stroke Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Rosenfield
authors.affiliation: The Institute for Heart, Vascular, & Stroke Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Yeh
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D002423:Cause of Death; D015331:Cohort Studies; D057505:Embolic Protection Devices / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D013223:Statistics as Topic; D015607:Stents; D020521:Stroke / Q000401:mortality / Q000517:prevention & control*; D015996:Survival Rate; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler; D014481:United States
keywords: carotid artery stenosis; carotid artery stenting; embolic protection devices; stroke