title: Transcervical Carotid Stenting With Dynamic Flow Reversal Demonstrates Embolization Rates Comparable to Carotid Endarterectomy.
abstract: OBJECTIVE
  To evaluate a series of patients treated electively with carotid endarterectomy (CEA), transfemoral carotid artery stenting with distal filter protection (CASdp), and transcervical carotid stenting with dynamic flow reversal (CASfr) monitored continuously with transcranial Doppler (TCD) during the procedure to detect intraoperative embolization rates.
  
  
  METHODS
  Thirty-four patients (mean age 67.6 years; 24 men) with significant carotid stenosis underwent successful TCD monitoring during the revascularization procedure (10 CEA, 8 CASdp, and 16 CASfr). Ipsilateral microembolic signals were segregated into 3 phases: preprotection (until internal carotid artery cross-shunted or clamped if no shunt was used, filter deployed, or flow reversal established), protection (until clamp/shunt was removed, filter retrieved, or antegrade flow reestablished), and postprotection (after clamp/shunt or filter removal or restoration of normal flow).
  
  
  RESULTS
  CASdp showed higher embolization rates than CEA or CASfr in the preprotection phase (p<0.001). In the protection phase, CASdp was again associated with more embolization compared with CEA and CASfr (p<0.001). In the postprotection phase, no differences between the revascularization therapies were observed. CASfr and CEA did not show significant differences in intraoperative embolization during any of the phases.
  
  
  CONCLUSIONS
  TCD recordings demonstrated a significant reduction in embolization to the brain during transcervical carotid artery stent placement with the use of dynamic flow reversal compared to transfemoral CAS using distal filters. No significant differences in microembolization could be detected between CEA and CASfr. The observed lower embolization rates and lack of adverse events suggest that transcervical CAS with dynamic flow reversal is a promising technique and may be the preferred method when performing CAS.
authors.affiliation: Department of Experimental Psychology, Ghent University, Ghent, Belgium Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium maarten.plessers@ugent.be.
authors.forename: Maarten
authors.initials: M
authors.lastname: Plessers
authors.affiliation: Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Van Herzeele
authors.affiliation: Department of Neurology, Ghent University Hospital, Ghent, Belgium.
authors.forename: Dimitri
authors.initials: D
authors.lastname: Hemelsoet
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, UK.
authors.forename: Nikil
authors.initials: N
authors.lastname: Patel
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, UK.
authors.forename: Emma M L
authors.initials: EM
authors.lastname: Chung
authors.affiliation: Department of Experimental Psychology, Ghent University, Ghent, Belgium.
authors.forename: Guy
authors.initials: G
authors.lastname: Vingerhoets
authors.affiliation: Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium.
authors.forename: Frank
authors.initials: F
authors.lastname: Vermassen
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy*; D057505:Embolic Protection Devices; D016894:Endarterectomy, Carotid / Q000009:adverse effects; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D005260:Female; D006801:Humans; D020766:Intracranial Embolism / Q000000981:diagnostic imaging / Q000209:etiology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D015607:Stents; D020521:Stroke / Q000000981:diagnostic imaging / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial
keywords: carotid artery stenting; carotid endarterectomy; embolization; flow reversal; mortality; stroke; transcervical stenting; transcranial Doppler ultrasonography