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Int J Angiol 2011; 20(1): 025-032
DOI: 10.1055/s-0031-1272546
ORIGINAL ARTICLE

© Thieme Medical Publishers

Risk Factors Predictive of Carotid Artery Stenting–Associated Subclinical Microemboli

Wei Zhou1 , 2 , Rosa Zareie2 , Maureen Tedesco1 , Simin Gholibeikian2 , Barton Lane2 , 3 , Tina Hernandez-Boussard1 , Allyson Rosen2 , 4
  • 1Department of Surgery, Stanford University, Stanford
  • 2VA Palo Alto Health Care System, Palo Alto
  • 3Department of Radiology, Stanford University, Stanford, California
  • 4Department of Psychiatry, Stanford University, Stanford, California
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Publication History

Publication Date:
14 March 2011 (online)

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ABSTRACT

Subclinical microemboli documented on diffusion-weighted magnetic resonance imaging (DWI) are common following carotid artery stenting (CAS) procedures despite absence of neurological symptoms. This study was to evaluate risk factors predictive of microemboli in patients undergoing protected CAS with a distal embolic protection device. All CAS patients who received pre- and postprocedural magnetic resonance imaging (MRI) evaluations for carotid interventions at a single academic institution from July 2004 to December 2008 were examined. Microemboli were defined by new hyperintensities on postoperative DWI with corresponding decreased diffusion. Risk factors including patient demographics, medical comorbidities, clinical symptoms, lesion morphologies, and perioperative information were examined, and logistic regression analyses were utilized to determine predictors of CAS-related microemboli. A total of 204 patients underwent carotid interventions (76 CAS and 128 carotid endarterectomies) during the study period; 167 of them, including 67 CAS patients, received both preoperative and postoperative MRIs. Among those who underwent protected CAS, the incidence of microemboli was 46.3% despite a relative low incidence of associated neurological symptoms (2.9%). Univariate and multivariate regression analyses showed that date of procedure (odds ratio [OR] 30.6 and p = 0.019) and preoperative transient ischemic attack symptoms (OR 9.24 and p = 0.009) were independent predictors of developing postoperative changes on DWI in the ipsilateral hemisphere, and age >76 years was predictive of having new lesions on DWI in the contralateral hemisphere (OR 6.11 and p = 0.026). Our study underscores that certain risk factors are significantly associated with CAS-related microemboli and that physician experience and patient selection are essential in improving outcome of CAS procedures.

KEYWORDS

CAS - microemboli - risk factors - DWI

REFERENCES

  • 1 Gurm H S, Yadav J S, Fayad P SAPPHIRE Investigators et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients.  N Engl J Med. 2008;  358 1572-1579
    CrossrefPubMedGoogle Scholar
  • 2 Yadav J S, Wholey M H, Kuntz R E Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients.  N Engl J Med. 2004;  351 1493-1501
    CrossrefPubMedGoogle Scholar
  • 3 Hammer F D, Lacroix V, Duprez T et al.. Cerebral microembolization after protected carotid artery stenting in surgical high-risk patients: results of a 2-year prospective study.  J Vasc Surg. 2005;  42 847-853 discussion 853
    CrossrefPubMedGoogle Scholar
  • 4 Jaeger H J, Mathias K D, Hauth E et al.. Cerebral ischemia detected with diffusion-weighted MR imaging after stent implantation in the carotid artery.  AJNR Am J Neuroradiol. 2002;  23 200-207
    PubMedGoogle Scholar
  • 5 Poppert H, Wolf O, Theiss W et al.. MRI lesions after invasive therapy of carotid artery stenosis: a risk-modeling analysis.  Neurol Res. 2006;  28 563-567
    CrossrefPubMedGoogle Scholar
  • 6 Rapp J H, Wakil L, Sawhney R et al.. Subclinical embolization after carotid artery stenting: new lesions on diffusion-weighted magnetic resonance imaging occur postprocedure.  J Vasc Surg. 2007;  45 867-872 discussion 872-874
    CrossrefPubMedGoogle Scholar
  • 7 Schlüter M, Tübler T, Steffens J C, Mathey D G, Schofer J. Focal ischemia of the brain after neuroprotected carotid artery stenting.  J Am Coll Cardiol. 2003;  42 1007-1013
    CrossrefPubMedGoogle Scholar
  • 8 Tedesco M M, Coogan S M, Dalman R L et al.. Risk factors for developing postprocedural microemboli following carotid interventions.  J Endovasc Ther. 2007;  14 561-567
    CrossrefPubMedGoogle Scholar
  • 9 Tedesco M M, Dalman R L, Zhou W, Coogan S M, Lane B, Lee J T. Reduction of postprocedure microemboli following retrospective quality assessment and practice improvement measures for carotid angioplasty and stenting.  J Vasc Surg. 2009;  49 607-612 discussion 612-613
    CrossrefPubMedGoogle Scholar
  • 10 Abu-Omar Y, Cader S, Guerrieri Wolf L, Pigott D, Matthews P M, Taggart D P. Short-term changes in cerebral activity in on-pump and off-pump cardiac surgery defined by functional magnetic resonance imaging and their relationship to microembolization.  J Thorac Cardiovasc Surg. 2006;  132 1119-1125
    CrossrefPubMedGoogle Scholar
  • 11 Barber P A, Hach S, Tippett L J, Ross L, Merry A F, Milsom P. Cerebral ischemic lesions on diffusion-weighted imaging are associated with neurocognitive decline after cardiac surgery.  Stroke. 2008;  39 1427-1433
    CrossrefPubMedGoogle Scholar
  • 12 Fearn S J, Pole R, Wesnes K, Faragher E B, Hooper T L, McCollum C N. Cerebral injury during cardiopulmonary bypass: emboli impair memory.  J Thorac Cardiovasc Surg. 2001;  121 1150-1160
    CrossrefPubMedGoogle Scholar
  • 13 Ghogawala Z, Westerveld M, Amin-Hanjani S. Cognitive outcomes after carotid revascularization: the role of cerebral emboli and hypoperfusion.  Neurosurgery. 2008;  62 385-395 discussion 393-395
    CrossrefPubMedGoogle Scholar
  • 14 Gossetti B, Gattuso R, Irace L et al.. Embolism to the brain during carotid stenting and surgery.  Acta Chir Belg. 2007;  107 151-154
    PubMedGoogle Scholar
  • 15 Restrepo L, Wityk R J, Grega M A et al.. Diffusion- and perfusion-weighted magnetic resonance imaging of the brain before and after coronary artery bypass grafting surgery.  Stroke. 2002;  33 2909-2915
    CrossrefPubMedGoogle Scholar
  • 16 Schlüter M, Reimers B, Castriota F et al.. Impact of diabetes, patient age, and gender on the 30-day incidence of stroke and death in patients undergoing carotid artery stenting with embolus protection: a post-hoc subanalysis of a prospective multicenter registry.  J Endovasc Ther. 2007;  14 271-278
    CrossrefPubMedGoogle Scholar
  • 17 Bazan H A, Pradhan S, Mojibian H, Kyriakides T, Dardik A. Increased aortic arch calcification in patients older than 75 years: implications for carotid artery stenting in elderly patients.  J Vasc Surg. 2007;  46 841-845
    CrossrefPubMedGoogle Scholar
  • 18 Bosiers M, De Donato G, Deloose K et al.. Are there predictive risk factors for complications after carotid artery stenting?.  J Cardiovasc Surg (Torino). 2007;  48 125-130
    PubMedGoogle Scholar
  • 19 Bosiers M, de Donato G, Deloose K et al.. Does free cell area influence the outcome in carotid artery stenting?.  Eur J Vasc Endovasc Surg. 2007;  33 135-141 discussion 142-143
    CrossrefPubMedGoogle Scholar
  • 20 Veith F J, Amor M, Ohki T et al.. Current status of carotid bifurcation angioplasty and stenting based on a consensus of opinion leaders.  J Vasc Surg. 2001;  33 (2 Suppl) S111-S116
    CrossrefPubMedGoogle Scholar
  • 21 Lin P H, Bush R L, Peden E K et al.. Carotid artery stenting with neuroprotection: assessing the learning curve and treatment outcome.  Am J Surg. 2005;  190 850-857
    PubMedGoogle Scholar
  • 22 Schnaudigel S, Gröschel K, Pilgram S M, Kastrup A. New brain lesions after carotid stenting versus carotid endarterectomy: a systematic review of the literature.  Stroke. 2008;  39 1911-1919
    CrossrefPubMedGoogle Scholar
  • 23 Gröschel K, Ernemann U, Schnaudigel S, Wasser K, Nägele T, Kastrup A. A risk score to predict ischemic lesions after protected carotid artery stenting.  J Neurol Sci. 2008;  273 112-115
    CrossrefPubMedGoogle Scholar
  • 24 Garami Z F, Bismuth J, Charlton-Ouw K M, Davies M G, Peden E K, Lumsden A B. Feasibility of simultaneous pre- and postfilter transcranial Doppler monitoring during carotid artery stenting.  J Vasc Surg. 2009;  49 340-344, 345, e1–e2 discussion 345
    CrossrefPubMedGoogle Scholar

Wei ZhouM.D. 

Division of Vascular and Endovascular Surgery, Stanford University

300 Pasteur Drive, H3640, Stanford, CA 94305-5642

Email: weizhou@stanford.edu