Key result
Intravascular ultrasound during carotid artery stenting with proximal embolic protection successfully identified intraluminal thrombus and plaque fragmentation, guiding further intraprocedural interventions.
Why the study?
Flow reversal during CAS decreases distal emboli in high-risk patients with difficult plaque morphology but does not offer intraprocedural visualization.
Does intravascular ultrasound (IVUS) improve intraprocedural visualization and management during carotid artery stenting with proximal protection in high-risk patients?
Case Report (n=3)
No
Does intravascular ultrasound (IVUS) improve intraprocedural visualization and management during carotid artery stenting with proximal protection in high-risk patients?
IVUS as an adjunct to carotid artery stenting under proximal embolic protection can help identify plaque fragmentation and thrombus, guiding further intraprocedural interventions to stabilize the plaque before flow reversal is stopped.
Carotid artery stenting (CAS) is an established treatment for patients at high-risk for endarterectomy. Patients who undergo CAS have been shown to have periprocedural microembolic events on transcranial Doppler ultrasonography. Flow reversal is often applied in these situations to prevent distal emboli and concurrently allow blood to flush into the common carotid artery. Patients who demonstrate soft plaque morphology that may embolize distally during CAS benefit from flow reversal. Even so, the all-stroke risk in these patients is nearly 1.4%. High-risk patients typically have more difficult plaque morphology; flow reversal decreases the rate of distal emboli but does not offer the intraprocedural visualization seen with intravascular ultrasound (IVUS). In this paper, we illustrate potential periprocedural outcomes associated with stenting of the stenotic carotid bifurcation under flow reversal and how IVUS influenced endovascular management. Three high-risk patients who underwent CAS with direct common carotid artery cutdown approaches due to common carotid ostia disease with flow-reversal proximal embolic protection also had intraprocedural IVUS performed to evaluate plaque morphology and stability before the protection system was removed. Case 1 illustrates no intraluminal thrombus on IVUS, requiring no further intervention after stent placement. Case 2 demonstrates intraluminal thrombus on IVUS requiring a second stent to stabilize plaque. Case 3 shows the inadequate resolution of thrombus after a second stent, which was addressed with balloon angioplasty. In our experience, using IVUS as an adjunct to CAS under proximal embolic protection helped demonstrate plaque morphology and plaque fragmentation after stent placement. These cases illustrate the potential benefit of allowing stabilization of the plaque before flow reversal is stopped.
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Morr et al. (2019) conducted a case report in Carotid artery stenosis (n=3). Intravascular ultrasound (IVUS) was evaluated on Intraprocedural visualization of plaque morphology and intraluminal thrombus. Intravascular ultrasound during carotid artery stenting with proximal embolic protection successfully identified intraluminal thrombus and plaque fragmentation, guiding further intraprocedural interventions.
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