Original ArticleCarotid Artery Stenting in Acute Stroke Using a Microporous Stent Device: A Single-Center Experience
Introduction
Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy for the treatment of carotid artery stenosis, particularly in patients who are high risk or have previously undergone a carotid endarterectomy or cervical radiotherapy. To date, most studies comparing the 2 treatments have concentrated on 2 patient groups: asymptomatic patients and patients presenting with transient ischemic attacks (TIAs) or completed stroke. The recent rapid increase in endovascular treatment for acute stroke has resulted in a third important group—patients with carotid artery stenosis presenting with acute stroke.
High-grade stenosis or occlusion of the cervical internal carotid artery (cICA) exists in 10%−20% of patients who present with an acute intracranial vessel occlusion.1 Acute stroke also can occur in the setting of cICA stenosis or occlusion with an intact intracranial circulation.
The most commonly used carotid stents are self-expanding. Braided stents and nitinol slotted tube stents represent 2 distinct categories. Stents also can be classified as open or closed cell based on cell geometry. This geometry influences properties such as flexibility, conformability, wall apposition, and plaque protrusion. More recently, stents with dramatically reduced cell size have been developed and represent a new category of devices—microporous stents. These stents have cell sizes similar to those of embolic protection devices (EPDs) with the potential to reduce the risk of distal plaque embolization during and following stent deployment. Three microporous carotid stents are currently available—the Casper Carotid Artery Stent System (MicroVention, Terumo, Tustin, California, USA), the Gore Carotid Stent (W.L. Gore, Flagstaff, Arizona, USA) and the CGuard Carotid Stent System (InspireMD, Tel Aviv, Israel). These devices feature a mesh covering with pore sizes between 165 and 500 μm and a free cell area of less than one half that of the next smallest stent.2, 3
The closed-cell nitinol Casper stent consists of a woven nitinol scaffold lined with a second micromesh layer. This design aims to prevent plaque protrusion while maintaining flexibility. Reduced plaque protrusion with the Casper stent is reported to be associated with a reduction in the number of postprocedural embolic lesions seen on diffusion-weighted magnetic resonance imaging.4, 5 In this study, we report the results of emergent carotid artery stenting (eCAS) using the Casper stent system in patients presenting with acute stroke at a tertiary hyperacute stroke referral center.
Section snippets
Methods and Materials
This study was approved by the local institutional review board. Clinical data of all patients who underwent CAS for carotid artery stenosis or occlusion using the Casper stent at a tertiary level hyperacute stroke center providing a 24-hour mechanical thrombectomy (MT) service between June 1, 2016, and June 1, 2018, were retrospectively collected from electronic hospital records and reviewed. Data collected included patient demographics, presenting symptoms, pre- and postprocedural National
Results
Twenty eCAS procedures were performed in 19 patients who presented with both acute stroke and clinically significant carotid artery stenosis over the study period (Table 1). All eCAS procedures during this time were performed using the Casper stent. Acute ischemic stroke classified the extracranial carotid lesion as symptomatic. Baseline patient demographics are outlined in Table 2 and Supplementary Table 1. One patient (5%) had previously undergone an ipsilateral carotid endarterectomy.
Twelve
Discussion
Previous carotid stent designs have focused on either providing optimal plaque coverage or flexibility. The Casper stent aims to achieve both through its novel double-layered micromesh design. Here, we report intermediate-term clinical outcomes using the Casper stenting system in patients with acute stroke and coexistent carotid artery stenosis.
Stent deployment was successful in all patients and DSA demonstrated patency of the treated carotid. A mTICI score of 3 was achieved in all nonemergent
Conclusions
CAS using the Casper stenting system is technically feasible and effective in patients with both acute stroke and symptomatic carotid artery stenosis with appropriate antiplatelet therapy.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.