Low embolisation risk with micromesh carotid stents

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Patients treated with either the Roadsaver (Terumo) or the CGuard (InspireMD) micromesh carotid stents had similar low risk of embolisation following carotid artery stenting at one Italian centre. The results were presented by Maria Antonella Ruffino (San Giovanni Battista University Hospital, Turin, Italy) at VEITHsymposium (13–17 November, New York, USA).

The data are from a prospective, single centre study of 50 consecutive patients implanted with micromesh stents (Roadsaver and CGuard) for carotid artery stenosis. The study sought to identify plaque activity at baseline using a diffusion weighted (DWI) magnetic resonance (MR) scan, and to evaluate the real incidence to new ischaemic lesions related to the interaction between the plaque and the two micromesh stents (plaque remodelling), with a DWI MR scan one hour after carotid artery stenting.

Investigators also wanted to identify whether there is a relationship between plaque activity (as demonstrated by DWI MR) and new ischaemic brain lesions at 24 hours after stenting with either micromesh stent, and whether DWI MR plaque positivity can predict the risk of new ischaemic lesions after CAS and so helping to identify high-risk patients.

Ruffino reported no significant difference between the two stents in terms of outcome following carotid artery stenting. One hour following stenting the Roadsaver stent group had zero incidences of new ischaemic lesions and the CGuard group had three (p=0.23). After 24 hours, the DWI MR scans showed that the Roadsaver group had six incidences of new ischaemic lesions and the CGuard group had 10 incidences (p=0.36).

Overall after 24 hours, new ischaemic lesions were found in 38% of patients (19/50) with a total of 34 lesions (1.79 lesions per patient) and 82% (28/34) of those new ischaemic lesions were ipsilateral. The majority of new ischaemic lesions (88.2%) appeared after 24 hours, while only 12% (4/34) appeared at the one-hour post-procedure scan.

Ruffino explained that while the study found no difference in terms of which carotid stent was used as it relates to the risk of embolisation, they did learn something about plaque activity. She explained that plaque activity can be easily and promptly evaluated by DWI MR and, when positive, it is predictive of a higher risk of new ischaemic lesions at 24 hours following carotid artery stenting (LR+ 6.26, p<0.0001).

All patients enrolled in the study underwent Doppler ultrasound at six, 12 and 24 months to evaluate in-stent restenosis and new external carotid artery stenosis or occlusion. Ruffino reported that again, there was no significant difference between the stents used. At 24-month follow-up, in-stent restenosis was recorded in 10% of patients (5/50, with one occurring at six months and four at one year)—three in the Roadsaver group and two in the CGuard group (p=0.19). In terms of new external carotid artery stenosis, Ruffino said that it was found in 4% of patients (2/50), all of which occurred in the Roadsaver group at six months follow-up.

Comparing their work with that of a meta-analysis of restenosis after carotid interventions and its relationship with recurrent ipsilateral stroke (Kumar et al, Eur J Vasc Endovasc Surg 2017), Ruffino indicated that the rate of in-stent restenosis was the same—10%. Similarly, compared to conventional carotid artery stenting (Brown et al, Journal of Vascular Surgery 2013), Ruffino’s series had 0% external carotid artery occlusion and 4% external carotid artery stenosis, while conventional carotid artery stenting mentioned in Brown’s work was associated with a 3.8% rate of external carotid artery occlusion.

Ruffino concluded that if these findings are confirmed by a larger cohort of patients and long-term follow-up, it can be said that the incidence of in-stent restenosis and external carotid artery stenosis following carotid artery stenting with micromesh stents are consistent with what has been reported for conventional carotid artery stents. She added that no difference was found between the two micromesh stents and that these stents may exert intrinsic embolic protection and impact positively on carotid artery stenting outcomes.

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