Carotid Artery Stenting With Proximal Embolic Protection via a Transradial or Transbrachial Approach: Pushing the Boundaries of the Technique While Maintaining Safety and Efficacy.
OBJECTIVE
To compare the feasibility and safety of proximal cerebral protection to a distal filter during carotid artery stenting (CAS) via a transbrachial (TB) or transradial (TR) approach.


METHODS
Among 856 patients who underwent CAS between January 2007 and July 2015, 214 (25%) patients (mean age 72±8 years; 154 men) had the procedure via a TR (n=154) or TB (n=60) approach with either Mo.MA proximal protection (n=61) or distal filter protection (n=153). The Mo.MA group (mean age 73±7 years; 54 men) had significantly more men and more severe stenosis than the filter group (mean age 71±8 years; 100 men). Stent type and CAS technique were left to operator discretion. Heparin and a dedicated closure device or bivalirudin and manual compression were used in TR and TB accesses, respectively. Technical and procedure success, crossover to femoral artery, 30-day major adverse cardiovascular/cerebrovascular events (MACCE; death, all strokes, and myocardial infarction), vascular complications, and radiation exposure were compared between groups.


RESULTS
Crossover to a femoral approach was required in 1/61 (1.6%) Mo.MA patient vs 11/153 (7.1%) filter patients mainly due to technical difficulty in engaging the target vessel. Five Mo.MA patients developed acute intolerance to proximal occlusion; 4 were successfully shifted to filter protection. A TR patient was shifted to filter because the Mo.MA system was too short. CAS was technically successful in the remaining 55 (90%) Mo.MA patients and 142 (93%) filter patients. The MACCE rate was 0% in the Mo.MA patients and 2.8% in the filter group (p=0.18). Radiation exposure was similar between groups. Major vascular complications occurred in 1/61 (1.6%) and in 3/153 (1.96%) patients in the Mo.MA and filter groups (p=0.18), respectively, and were confined to the TB approach in the early part of the learning curve. Chronic radial artery occlusion was detected by Doppler ultrasound in 2/30 (6.6%) Mo.MA patients and in 4/124 (3.2%) filter patients by clinical assessment (p=0.25) at 8.1±7.5-month follow-up.


CONCLUSIONS
CAS with proximal protection via a TR or TB approach is a feasible, safe, and effective technique with a low rate of vascular complications.
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy piero.montorsi@unimi.it.
Piero
P
Montorsi
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Stefano
S
Galli
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Paolo M
PM
Ravagnani
Department of Cardiology, Ospedale di Desio, Milan, Italy.
Simone
S
Tresoldi
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Giovanni
G
Teruzzi
Department of Cerebrovascular Diseases, Neurological Institute "Carlo Besta," Milan, Italy.
Luigi
L
Caputi
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Daniela
D
Trabattoni
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Franco
F
Fabbiocchi
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Giuseppe
G
Calligaris
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Luca
L
Grancini
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Alessandro
A
Lualdi
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Stefano
S
de Martini
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Antonio L
AL
Bartorelli
D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods / Q000401:mortality; D000925:Anticoagulants / Q000627:therapeutic use; D001916:Brachial Artery / Q000000981:diagnostic imaging; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D000072226:Computed Tomography Angiography; D057505:Embolic Protection Devices; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control; D011474:Prosthesis Design; D017534:Radial Artery / Q000000981:diagnostic imaging; D000069079:Radiation Exposure; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D013997:Time Factors; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler
D000925:Anticoagulants
brachial artery access; carotid artery stent; cerebral protection; embolic protection; filter; proximal embolic protection; radial artery access