Editorial Comment—Utility of Abciximab During Carotid Stenting When Distal Protection Is Contraindicated
We read with great interest the article by Kopp et al in this issue of Stroke.1 In this article, patients undergoing carotid stenting were randomized to receive either aspirin, clopidogrel, and heparin therapy, or adjunct therapy with an abciximab bolus and infusion for 12 hours. A third cohort of 30 patients underwent stenting with filter protection using the same regimen (without adjunctive abciximab). Filter protection resulted in the greatest protection from de novo ischemic lesions demonstrated on MRI and was associated with the fewest periprocedural transient ischemic attacks and total ischemic events.
The authors use flow cytometry and immunoassays to convincingly demonstrate the utility of abciximab in reducing postintervention activated monocyte-platelet aggregates and TF-positive monocytes, thus limiting the potential for thrombus propagation. Nonetheless, the benefit of abciximab was still inferior to that of filter distal protection. Additionally, the potential for bleeding complications, especially in the setting of chronically ischemic brain, is greater with the use of abciximab.2 Thus, filter protection provides greater benefit with less bleeding risk, suggesting that distal protection should be considered for all patients requiring carotid stenting.
Although recent data exist in which the utility of distal protection devices in high-risk carotid patients is shown,3,4 this article provides evidence for the use of filter protection in all patients undergoing carotid stenting. Perhaps the benefit of filter protection is the ability to prevent ischemia resulting from embolic debris (directly) and from early periprocedural decrease of soluble CD40 ligand. Reduced MPA, monocyte TF, and F1.2 generation was also seen with filter protection, as well as with abciximab administration. In those patients in whom the internal carotid artery is not compatible with the delivery of protection devices because of anatomical constraints (small diameter or excessive tortuosity), abciximab administration may be a good “second-line” defense against periprocedural stroke in patients.
Kopp CW, Steiner S, Nasel C, Seidinger D, Mlekusch I, Lang W, Bartok A, Ahmadi R, Minar E. Abciximab reduces monocyte tissue factor in carotid angioplasty and stenting. Stroke. 2003; 34: 2560–2567.
Gruberg L. SAPPHIRE: Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy. In: Medscape www.medscape.com/viewarticle/445125. November, 2002. Accessed July 21, 2003.
Yadav J. Stenting and Angioplasty With Protection in Patients at HIgh Risk for Endarterectomy (SAPPHIRE) 30-day complications. American Heart Association, 2002. www.crtonline.org/documents/ SAPPHIRE_11.2. ppt. Accessed June 2, 2003.