Embolic protection may be feasible in TEVAR

HOLLYWOOD, Fla. — The results of a small pilot study indicate that it may be feasible and effective to provide embolic protection during thoracic endovascular aortic repair, or TEVAR, according to a presentation at the International Symposium on Endovascular Therapy.

“We are now able to treat a much wider population and an older population [with TEVAR],” Gagandeep Grover, MBBS, from Imperial College London, said. “However, stroke still remains a real risk in these patients, with up to 10% reported risk, especially the more proximal the landing zone. Significantly, there is a very high risk for silent cerebral infarction with these cases.” She added that silent cerebral infarction is associated with stroke, dementia, depression and neurocognitive decline.

“Cerebral embolization through instrumentation of a diseased aortic arch has been identified as a principal risk factor,” Grover said. In one single-center study of 52 patients who had TEVAR, there was an 81% rate of cerebral infarction and a 68% rate of silent cerebral infarction.

In fact, she said, “every single patient had embolization throughout the procedure,” with the highest rates occurring during stent deployment and contrast injection. In addition, 88% of patients with silent cerebral infarction had neurocognitive decline after the procedure, which was still present at 6 weeks in those older than 60 years.

As a result, Grover said, a pilot study has been conducted in four patients undergoing TEVAR of a percutaneous embolic protection device (Sentinel, Claret Medical), which has been successfully used in patients undergoing transcatheter aortic valve replacement and transcatheter mitral valve repair.

The researchers recorded embolization throughout the procedure, including during deployment and retrieval of the embolic protection device, she said.

At 6 weeks, none of the patients experienced any neurocognitive decline.

When Grover and colleagues performed MRI on the patients, two of them had no new lesions and the other two had “very small-volume lesions,” she said.

All filters underwent a histopathological analysis, which indicated that each of them captured some debris, “a mixture of thrombus and arterial wall,” Grover said.

“Our initial results have been very encouraging,” she concluded. “We plan to continue our pilot study. We want to assess how many patients we can safely and feasibly get the device into, and what percentage of TEVARs, emergency and elective, are suitable for the device. Hopefully, we will be able to do [a randomized controlled trial] looking at volume of [silent cerebral infarctions] as a primary outcome.” – by Erik Swain

Reference:

Grover G. Session VII: EVAR State of the Art. Presented at: International Symposium on Endovascular Therapy; Feb. 6-10, 2016; Hollywood, Fla.

Disclosure: Grover reports no relevant financial disclosures.