Periprocedural Outcomes of Carotid Artery Stenting According to Embolic Protection Strategy: A 20-Year Single-Center Experience.

Abstract

This study aimed to evaluate the impact of embolic protection strategies on outcomes in asymptomatic patients undergoing carotid artery stenting (CAS). We retrospectively analyzed 312 consecutive asymptomatic patients with high-grade carotid stenosis (≥70% by North American Symptomatic Carotid Endarterectomy Trial criteria) who underwent CAS between 2005 and 2024. Protection strategies were categorized into 5 groups: distal filter only, proximal with distal filter, distal balloon only, proximal with distal balloon, and flow reversal. The primary outcome was 30-day major adverse cardiovascular and cerebrovascular events (MACCE). Secondary outcomes included diffusion-weighted imaging (DWI) lesion burden. The overall 30-day MACCE rate was 2.2% (7/312). The MACCE rate was significantly lower with proximal protection strategies than with filter-based protection (0.9% vs. 7.7%; P = 0.005). DWI-positive lesions were detected in 53% patients. High embolic burden (>5 lesions) was more frequent with filter-based protection (23% vs. 13%, P = 0.046). In multivariable analysis, older age was the only independent predictor of high embolic burden (adjusted odds ratio 1.06 per year, 95% confidence interval 1.01-1.11; P = 0.026). Distal filter use showed a consistent trend toward a higher rate of procedural DWI lesions, though this did not reach statistical significance (adjusted odds ratio 2.04, 95% confidence interval 0.95-4.35, P = 0.066). The embolic protection strategy significantly influenced periprocedural outcomes in patients with asymptomatic CAS. These findings underscore the importance of individualized embolic protection device selection, particularly in older patients, and suggest the need for comprehensive medical management when prophylactic revascularization is pursued.