MicroNET-covered stent (CGuard) routine use in acute carotid-related stroke – SAFEGUARD-STROKE Study: response to the Buffalo Group commentary

Figures

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  Figure 1. Photograph of the MicroNET-covered carotid stent (CGuard). Note a widely open-cell nitinol frame (exhibiting a high adaptability to curves), wrapped on the outside by the MicroNET sleeve.

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  Figure 2. Example of ECA-to-ICA flow with balloon occlusion of only the common carotid artery (mono-balloon catheter), resulting in lack of effective cerebral protection A 56-year-old male patient with recent left-hemispheric TIA with severe left carotid bifurcation stenosis (mixed plaque with both calcifications and intraluminal hypoechogenic elements on duplex ultrasound imaging) was treated with 2nd-generation stent CAS for primary stroke prevention. In this setting, proximal protection was considered the system of choice [11, 36]. A mono-balloon system [31] was used because of the significant risk of causing iatrogenic embolism with a double-balloon system (that would require positioning of the distal balloon in ECA) [33]. A mono-balloon proximal neuroprotection system was positioned in the CCA and inflated (A, yellow arrow; “back” pressure 43/38 mm Hg), and antegrade contrast injection (A, white arrows) was performed for subsequent lesion visualization under flow reversal (note the antegrade opacification of the superior thyroid artery in A, red arrowheads). Flow reversal was established by opening the stopcock of the balloon catheter system. Note the disappearance of the contrasted…

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  Figure 3. New cerebral embolism in eCAS with balloon catheter effective occlusion of the CCA only and residual flow towards the brain (cf. Figure 2) A 74-year-old female patient with ‘stuttering’ left hemispheric carotid-related non-tandem stroke (National Institutes of Health Stroke Scale (NIHSS) fluctuating from 3 to 7, Alberta stroke programme early CT score (ASPECTS) 10) was treated with eCAS under proximal cerebral protection. A double-balloon proximal neuroprotection system was inserted in the ECA and CCA; the CCA balloon was inflated (A, green arrowhead; “back” pressure 50/44 mm Hg) while the ECA balloon could not be inflated (A, red arrowhead; balloon dysfunction possibly due to significant calcifications in the proximal CCA in the absence of a significant stenosis); antegrade contrast injection. B shows absence of an intracranial large vessel occlusion (LVO), consistent with prior information from computed tomography angiography. The lesion was predilated with a small coronary balloon followed by insertion of a 9.0 × 30 mm anti-embolic MicroNET-covered stent (C). The stent was implanted and post-dilated (D; 5.0 mm semi-compliant balloon). There was an optimal procedural result at…