on September 28, 2006
Published online before print September 28, 2006, doi: 10.1161/01.STR.0000244781.68371.59
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Submitted on June 7, 2006
From the Unitat Neurovascular, Servei de Neurología (M.R., C.A.M., M.R., J.A.-S.) and Servei d’Angiologia Cirurgia Vascular i Endovascular (B.A., M.M.), Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Spain. * To whom correspondence should be addressed. E-mail: marcriboj{at}hotmail.com.
Background and Purpose--Transfemoral carotid stenting, despite becoming very frequent, has some limitations such as difficult groin access in few patients, lack of distal protection during filter placement, or embolization despite protection. Transcervical stenting (TCS) is a novel technique during which a common carotid to jugular vein shunt is placed creating a protective reversal flow in the internal carotid artery after proximal common carotid artery (CCA) clamping. We aim to study, with transcranial Doppler (TCD), cerebral flow changes and microemboli detection during transcervical stenting. Methods--From September 2005 to March 2006, of 65 consecutive patients eligible for carotid revascularization, 23 were considered high risk (sapphire criteria) and underwent TCS. Neurologic examination was performed before and after the procedure by a neurologist and a preprocedure vascular reactivity TCD examination was done in all patients. Results--After CCA clamping, flow inversion was observed in the anterior cerebral artery, supplying blood to the middle cerebral artery (MCA) and internal carotid artery (reversal). TCD did not detect any air/solid emboli during stent deployment and angioplasty confirming the reversal flow protection hypothesis. Mean reversal flow time was 15.4 minutes; in all cases, substantial MCA flow was present during CCA clamping (initial mean velocity 30 cm/s), and a slow gradual increase was observed traducing collateral flow recruitment (mean velocity after 5 minutes 36 cm/s, P<0.001). Flow increase was observed in all patients except in those with preprocedural exhausted ipsilateral vascular reactivity (16% versus 2%, P=0.036). The only in-procedure complication was one transient ischemic attack. After CCA unclamping, normal antegrade flow was restored in anterior cerebral artery and mean final MCA velocity increased 16% according to preprocedure flow. Conclusions--TCS with protective internal carotid artery flow reversal can eliminate showers of micoremboli during stent deployment making it a promising carotid revascularization technique in high-risk patients with carotid stenosis.
Accepted on August 8, 2006
Transcranial Doppler Monitoring of Transcervical Carotid Stenting With Flow Reversal Protection. A Novel Carotid Revascularization Technique
Marc Ribo MD, PhD*;
Key words: carotid artery • carotid stenosis • stenting • TCD
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