Dr Alberto Cremonesi, from Villa Maria Cecilia Hospital Cotignola, Italy, presented a study which evaluated the impact of proximal endovascular clamping devices on 30-day clinical neurological outcome in percutaneously treated patients for symptomatic and asymptomatic soft echolucent carotid plaques. Previously, surgical intervention was seen as the gold standard as filterwires were not recommended due to the significant amount of embolic particles released during the intervention. However, Cremonesi claims that improvements in protected carotid artery stenting procedures with proximal endovascular clamping devices have shown how almost all types of challenges can be nowadays successfully addressed (high risk lesions, long sub-occlusive lesions, unstable and ulcerated plaques).
A total of 79 patients (62 men; mean age 63 years) with documented severe carotid stentosis (mean 83%) underwent percutaneous stenting of the extracranial carotid artery. The majority of patients (86%) were symptomatic. Echolucency was measured using the grey scale median (GSM). In all patients the GSM was <25, categorising the lesions as soft plaques at high risk for periprocedural embolic complications. The endovascular procedure was conducted using several types of stents (alloy/braided, thread frame, nitinol, cylindrical/tapered shape), with cerebral neuroprotection achieved using proximal endovascular clamping devices. The MO.MA cerebral protection device (proximal flow blockage), from Invatec, was utilised in 66 patients (84.6%), the remainder used the PAES (flow reversal) devices, from AteriA, recently acquired by Gore. Cremonesi and his team reported 100% success rate for stent implantation, with the average duration of proximal clamping reported at 5 minutes. Transient neurological symptoms were reported in 3.85 per cent of patients and debris was collected in 93% of patients. There was one stroke and one death from any cause reported at 30-days. Cremonesi concluded that carotid stenting indications could be extended to soft plaques (with a GSM <25), with a well trained, endovascular team experienced in the use of proximal clamping devices. He said, "Specifically the results from the MO.MA device in this initial series were very encouraging in the treatment of soft plaques." Although he did acknowledge that a specific learning curve may exist for the proper use of both types of proximal protection devices. Cremonesi concluded by stating, "The main objective is to improve stenting and proximal endovascular clamping devices, but the most important thing is that we are moving towards protecting the patient, not just the procedure."