Embolization during carotid angioplasty and stenting : what is the optimal method for detecting embolic debris and its sequelae?

Overview

Although the initial randomized trials evaluating the efficacy of carotid angioplasty and stenting (CAS) relative to carotid endarterectomy (CEA) were favorable for CAS, more recent trials have not been universally supportive and have instead highlighted the fact that patient selection may be the key to reducing poor outcomes following percutaneous carotid intervention. Because adverse neurologic events of sufficient severity to be detected by neurologic exam are rare, it is helpful to have more sensitive surrogates of neurologic outcome, such as neurocognitive testing, transcranial Doppler, diffusion-weighted magnetic resonance imaging, and particulate analysis of captured embolic debris. These techniques allow for the evaluation of embolic phenomenon and its sequelae during CAS, which is likely responsible for the majority of adverse neurologic outcomes with this new modality. By correlating the data gathered by these techniques with the perioperative patient, lesion, or device characteristics in those undergoing CAS, one may ultimately be able to better identify and avoid percutaneous treatment in patients who are at heightened risk of embolic phenomenon and adverse clinical outcomes.