Determinants of Embolic Risk During Angioplasty and Stenting Neurologic Symptoms and Coronary Artery Disease Increase Embolic Risk

Background: Carotid angioplasty and stenting (CAS) has proven to be a potential alternative to carotid endarterectomy in the treatment of severe carotid disease. Patient selection has emerged as a means of optimizing the outcomes of CAS. Objective: To determine whether the presence of preprocedural neurologic symptoms and having a history of coronary artery disease (CAD) are associated with greater embolic risk during CAS through analysis of the embolic debris captured within protective filters. Methods: A total of 233 consecutive CAS procedures were performed between 2003 and 2009. Particles of embolic debris within the filters were quantified by photomicroscopy and video imaging software. Particulate size was determined by measuring the length along the longest axis. Preprocedural neurologic symptoms included transient ischemic attack, cerebrovascular accident, and amaurosis fugax. History of CAD included prior myocardial infarction, coronary artery bypass grafting, congestive heart failure, or abnormal stress test. Results: Of the 137 (58.8%) filters that were analyzed (mean age, 71.3 +/- 9.1 years, 56.9% male), 52 (38.0%) and 80 (58.4%) filters were from symptomatic and CAD patients, respectively. Filters of symptomatic (S) patients contained both a greater number and larger mean particle size compared with those of asymptomatic (AS) patients (S: 15.8 +/- 13.5 particles vs. AS: 9.8 +/- 8.7 particles, P = 0.002; S: 507 +/- 389 mu m vs. AS: 398 +/- 181 mu m, P = 0.03; respectively). Filters from CAD patients also had a greater number of particles, but trended toward smaller minimum size than those in non-CAD patients (CAD: 14.4 +/- 12.8 particles vs. non-CAD: 8.8 +/- 7.4 particles, P = 0.002; CAD: 167 +/- 172 mu m vs. 228 +/- 203 mu m, P = 0.06). Conclusions: These findings suggest that the presence of preprocedural neurologic symptoms and a history of CAD are associated with increased embolization during CAS. Therefore, the benefit of carotid stenting should be tempered by the potential for increased perioperative events in both symptomatic and CAD patients.