Is it possible to prevent cerebral embolization by improving the design and technology of carotid stent implantation?

ABSTRACT

Introduction

The prevention of atherosclerotic plaque fragmentation during carotid artery stenting is a fundamental problem in decreasing the risk of disability of patients. The goal of this review is to clarify whether the stent design can have a decisive impact on the rate of intraoperative and postoperative complications.

Areas covered

Different designs of the carotid stents are briefed and the advantages and disadvantages of different stent designs are discussed as well as the results of their clinical use. Various solutions are presented to reduce cerebral embolism during carotid artery stenting.

Expert opinion

There is no conclusive evidence for the benefits of closed cell and hybrid stents. The stent design cannot completely resolve the problem of cerebral embolism. Most of the events of cerebral microembolism occur at the stages of stent delivery rather than protrusion of an atherosclerotic plaque in the long-term follow-up. Most likely, minimization of the risks for periprocedural and postprocedural strokes requires not only the new solutions in stent design as well as the corresponding delivery systems and brain embolic protection systems, but also the new strategies of preprocedural drug stabilization of the atherosclerotic plaque in the carotid artery.

Abbreviations: CAS, carotid artery stenting; CE, carotid endarterectomy; DW-MRI, diffusion-weighted magnetic resonance imaging; ECA, external carotid artery; ICA, internal carotid artery; IVUS, intravascular ultrasound examination; OCT, optical coherence tomography

KEYWORDS:

• Carotid artery
• carotid stenosis
• carotid stenting
• stent design
• plaque protrusion
• cerebral embolism
• protection device

Article highlights

• Dual-layer and closed-cell stents cannot completely protect against cerebral microembolism.

• Symptomatic and asymptomatic carotid artery stenosis can be safely performed using dual-layer and single-layer carotid stents

• The CAS complications as an ischemic stroke may depend on embolic protection devices, vessel anatomy, carotid artery morphology, degree of shaggy aorta, symptomaticity of carotid artery lesion, the age of ≥70 year, reduced cerebral reserve, and the experience of operator

• It is worthwhile to identify the relationship not only between stent design and stroke, but also the appearance of new silent ischemic foci, which may be predictors of cognitive disorders in the future.

• Preoperative therapy is necessary to stabilize the atherosclerotic plaque.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose. 

Additional information

Funding

This paper was not funded.