title: Double balloon protection during carotid artery stenting for vulnerable carotid stenosis reduces the incidence of new brain lesions.
abstract: The use of distal filter protection alone is associated with a high risk of ischemic complications when vulnerable carotid stenosis is treated by carotid artery stenting (CAS). Double balloon protection, a combination of distal balloon protection and proximal balloon occlusion, can be utilized. We assessed the outcome and complications of the double balloon protection method for vulnerable carotid stenosis.
  
  
  
  Among 130 patients who underwent CAS from 2009 to 2014, we enrolled the following patients: those whose target lesion was vulnerable as evaluated by MRI, i.e., a signal ratio of plaque to posterior cervical muscle on T1-weighted images before CAS of ≥1.5, and those who underwent diffusion-weighted imaging (DWI) studies within 48 h after the procedure. Ninety patients were enrolled. We investigated DWI findings of the double balloon protection group compared with those of the simple distal balloon protection and distal filter protection groups.
  
  
  
  Sixty-four patients (71 %) underwent double balloon protection, 15 patients (17 %) simple distal balloon protection, and 11 patients (12 %) distal filter protection. Symptomatic embolic complications and new lesions on DWI after CAS were significantly less common in patients undergoing double balloon protection compared to distal balloon protection or distal filter protection (0 % vs. 20 %, 9 %, P < 0.01, and 30 % vs. 67 %, 82 %, P < 0.01, respectively). Logistic regression analysis also identified the odds ratio of double balloon protection for new lesions on DWI after CAS of 0.23 (95 % confidence interval: 0.07-0.70, P < 0.01) compared to simple distal protections.
  
  
  
  In the patients who underwent CAS for vulnerable carotid stenosis, double balloon protection was an independent significant factor associated with a reduction in the risk of new lesions on DWI after the procedure compared to conventional distal protections.
authors.affiliation: Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, 060-8556, Japan. nakazaki@sapmed.ac.jp.
authors.forename: Masahito
authors.initials: M
authors.lastname: Nakazaki
authors.affiliation: Department of Neuroendovascular Therapy, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.|Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.
authors.forename: Tadashi
authors.initials: T
authors.lastname: Nonaka
authors.affiliation: Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.
authors.forename: Akira
authors.initials: A
authors.lastname: Takahashi
authors.affiliation: Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.
authors.forename: Yasuyuki
authors.initials: Y
authors.lastname: Yonemasu
authors.affiliation: Department of Neuroendovascular Therapy, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.|Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.
authors.forename: Tatsufumi
authors.initials: T
authors.lastname: Nomura
authors.affiliation: Department of Neuroendovascular Therapy, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.|Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Onda
authors.affiliation: Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.
authors.forename: Osamu
authors.initials: O
authors.lastname: Honda
authors.affiliation: Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.
authors.forename: Yuji
authors.initials: Y
authors.lastname: Hashimoto
authors.affiliation: Department of Public Health, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, 060-8556, Japan.
authors.forename: Hirofumi
authors.initials: H
authors.lastname: Ohnishi
authors.affiliation: Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, 060-8556, Japan.
authors.forename: Masanori
authors.initials: M
authors.lastname: Sasaki
authors.affiliation: Department of Neurosurgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Hokkaido, 003-0026, Japan.
authors.forename: Masahiko
authors.initials: M
authors.lastname: Daibo
authors.affiliation: Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, 060-8556, Japan.
authors.forename: Osamu
authors.initials: O
authors.lastname: Honmou
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D021721:Balloon Occlusion / Q000009:adverse effects* / Q000379:methods; D002339:Carotid Arteries / Q000000981:diagnostic imaging; D016893:Carotid Stenosis / Q000628:therapy*; D038524:Diffusion Magnetic Resonance Imaging; D005260:Female; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D015607:Stents / Q000009:adverse effects*
keywords: Carotid artery stenting; Carotid stenosis; Diffusion-weighted imaging; Double balloon protection; Vulnerable plaque