Elsevier

World Neurosurgery

Volume 127, July 2019, Pages e1003-e1012
World Neurosurgery

Original Article
Carotid Artery Stenting in Acute Stroke Using a Microporous Stent Device: A Single-Center Experience

https://doi.org/10.1016/j.wneu.2019.04.024Get rights and content

Background

Carotid artery stenting (CAS) is an established treatment for carotid artery stenosis, typically in a semielective or elective setting. The growth of mechanical thrombectomy for acute stroke has led to an increased use of emergent carotid artery stenting (eCAS). This single-center retrospective case series evaluates the safety and efficacy of eCAS using a dual-layer micromesh nitinol stent to treat carotid artery stenosis in the acute stroke setting.

Methods

Ethics approval was granted by the institutional review board. Clinical data of all patients who underwent CAS using the Casper dual-layer micromesh nitinol stent system (MicroVention, Terumo, Tustin, California, USA) at a tertiary level 24-hour endovascular thrombectomy service over a 2-year period (June 2016−June 2018) were retrospectively obtained and reviewed.

Results

Twenty eCAS procedures were performed in 19 patients over the study period. Most patients had tandem lesions (12/20; 60%). Median National Institute of Health Stroke Scale score on admission was 17 (interquartile range 9–22). Stent deployment was technically successful in all patients. Recanalization rate was 95%. Symptomatic intracranial hemorrhage occurred in 2 patients (10%), both resulting in death. No other procedure-related deaths occurred. Stent thrombosis occurred in 2 patients. One delayed embolic stroke occurred. No other stent-related complications occurred. Median National Institute of Health Stroke Scale score at 24 hours postprocedure was 3 (interquartile range 1–12). Six patients had a good clinical outcome (modified Rankin Scale score between 0 and 2) at 3- to 6-month follow-up (38%).

Conclusions

eCAS using the Casper stenting system is effective and technically feasible in the acute stroke setting, although the ideal antiplatelet and anticoagulation regime is not clearly established.

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.

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