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Proximal occlusion fails to outperform distal filter in cerebral outcomes
Cerebral protection with proximal occlusion did not significantly reduce development of new embolic cerebral lesions or improve clinical outcomes compared with distal filter among patients who underwent carotid artery stenting, according to findings from a recent meta-analysis.
The researchers wrote that new cerebral lesions as observed by diffusion-weighted MRI may be a surrogate endpoint for embolization. The current meta-analysis of randomized and observational trials comparing proximal occlusion and distal filter during carotid artery stenting included 392 patients from seven studies, with new cerebral lesions as the primary endpoint. Incidence of new ipsilateral and contralateral cerebral lesions, along with mortality and cerebrovascular events, served as secondary outcome measures.
Patients received proximal occlusion in 193 cases, and 199 patients received distal filter. Among 368 patients who underwent diffusion-weighted MRI at 48 hours after stenting, new cerebral lesions occurred in 48.3%. Ipsilateral lesions occurred in 161 patients, and 44 patients developed new contralateral cerebral lesions out of 333 patients with evaluable data. Risk estimates for new cerebral lesions were significantly affected by several factors, including diabetes, stenosis at baseline and symptoms.
Compared with distal filter, proximal occlusion did not significantly reduce the risk for new cerebral lesions overall (OR = 0.65; 95% CI, 0.28-1.52) or for ipsilateral (OR = 0.62; 95% CI, 0.26-1.47) or contralateral lesions specifically (OR = 0.56; 95% CI, 0.28-1.13).
The overall rate of death or cerebrovascular events was 4.1% over a follow-up of 135 days (range 30 to 360 days). The researchers observed no significant reduction in risk for either outcome with proximal occlusion compared with distal filter (OR = 0.6; 95% CI, 0.22-1.63).
“In daily practice, despite the clinical safety of contemporary protected [carotid artery stenting], subclinical cerebral embolization still occurs,” the researchers wrote. “Cerebral protection with [proximal occlusion] versus [distal filter] neither reduces cerebral embolization nor impacts on clinical outcomes.” – by Rob Volansky
Disclosure: The researchers report no relevant financial disclosures.