Embolic protection devices for carotid artery stenting: A network meta-analysis

Stefanos Giannopoulos; Marios Sagris; Spyridon Giannopoulos; Andreas Tzoumas; Damianos G Kokkinidis; Pavlos Texakalidis; George Koutsias; Panagiotis Volteas; Li Jing; Rafael D Malgor

doi:10.1177/17085381221140616

Embolic protection devices for carotid artery stenting: A network meta-analysis

Vascular. 2022 Nov 17:17085381221140616. doi: 10.1177/17085381221140616. Online ahead of print.

Affiliations

¹ Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA.
² General Hospital of Nikaia, Athens, Greece.
³ First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece.
⁴ Department of Medicine, University of Cincinnati Health, Cincinnati, OH, USA.
⁵ Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT, USA.
⁶ Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
⁷ 37783Aristotle University of Thessaloniki, Division of Vascular Surgery, 2(nd) Department of Surgery, Thessaloniki, Greece.
⁸ Division of Vascular Surgery and Endovascular Therapy, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA.

PMID: 36394946
DOI: 10.1177/17085381221140616

Abstract

Objectives: Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications.

Methods: A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

Results: Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups.

Conclusions: PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.

Keywords: CAS; EPD; carotid artery; carotid stenting; embolic protection; neuroprotection.