title: Proximal balloon occlusion versus distal filter protection in carotid artery stenting: A meta-analysis and review of the literature.
abstract: BACKGROUND
  Carotid artery stenting (CAS) is typically performed using embolic protection devices (EPDs) as a means to reduce the risk of procedure-related stroke. In this study, we compared procedural morbidity and mortality associated with distal (D-EPD) vs. proximal (P-EPD) protection.
  
  
  METHODS
  MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1998 through May 2015. Only studies comparing (D-EPD) and (P-EPD) were included. Two independent reviewers selected and appraised studies and extracted data in duplicate. Random-effects meta-analysis was used to pool outcomes across studies. Heterogeneity of treatment effect among studies was assessed using the I2statistics. Publication bias was assessed using inspection of funnel plots. The primary endpoints included 30-day mortality and stroke. Secondary endpoints included new cerebral lesions on diffusion-weighted magnetic resonance imaging (DW-MRI) and contralateral lesions on DW-MRI.
  
  
  RESULTS
  A total of 12,281 patients were included from 18 studies (13 prospective and 5 retrospective) comparing (D-EPD) and (P-EPD) in the setting of CAS. The mean patient age was 69 years and 64% of patients were male. No evidence of publication bias was detected. There was no significant difference between the two modalities in terms of the risk of stroke (risk difference [RD] 0.0, 95% confidence interval [CI] -0.01 to 0.01) or mortality (RD 0.0, 95% CI -0.01 to 0.01) nor was there any difference in the incidence of new cerebral lesions on DW-MRI or contralateral DW-MRI lesions.
  
  
  CONCLUSIONS
  In patients undergoing CAS, both D-EPD and P-EPD provide similar levels of protection from peri-procedural stroke and 30 days mortality. © 2016 Wiley Periodicals, Inc.
authors.affiliation: Cardiovascular Medicine Department, University of Missouri-Columbia School of Medicine, Columbia, Missouri.
authors.forename: Jad
authors.initials: J
authors.lastname: Omran
authors.affiliation: Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, La Jolla, California.
authors.forename: Ehtisham
authors.initials: E
authors.lastname: Mahmud
authors.affiliation: Department of Cardiology, Ochsner Clinic Foundation, New Orleans, Louisiana.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: White
authors.affiliation: Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
authors.forename: Herbert D
authors.initials: HD
authors.lastname: Aronow
authors.affiliation: Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Douglas E
authors.initials: DE
authors.lastname: Drachman
authors.affiliation: Lankenau Heart Institute, Wynnewood, Pennsylvania.
authors.forename: William
authors.initials: W
authors.lastname: Gray
authors.affiliation: Cardiovascular Medicine Department, University of Missouri-Columbia School of Medicine, Columbia, Missouri.
authors.forename: Obai
authors.initials: O
authors.lastname: Abdullah
authors.affiliation: Section of Cardiovascular Disease, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
authors.forename: Mazen
authors.initials: M
authors.lastname: Abu-Fadel
authors.affiliation: Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Belal
authors.initials: B
authors.lastname: Firwana
authors.affiliation: Prairie Cardiovascular Consultants, Springfield, Illinois.
authors.forename: Gergory
authors.initials: G
authors.lastname: Mishkel
authors.affiliation: Prairie Cardiovascular Consultants, Springfield, Illinois.
authors.forename: Ashraf S
authors.initials: AS
authors.lastname: Al-Dadah
mesh_terms: D021721:Balloon Occlusion / Q000379:methods*; D016893:Carotid Stenosis / Q000150:complications / Q000628:therapy*; D057505:Embolic Protection Devices; D020766:Intracranial Embolism / Q000209:etiology / Q000517:prevention & control*; D012307:Risk Factors
keywords: carotid artery stenting; distal filter protection; proximal balloon occlusion; stroke