Unprotected carotid artery stenting in modern practice


  • Disclosures: Dr. Yeh is an investigator at the Harvard Clinical Research Institute and has served as a consultant for the Kaiser Permanente Division of Research. Dr. White is an investigator for the Carotid Stenting Boston Scientific Surveillance Program (CABANA) trial from Boston Scientific Corp. Dr. Rosenfield reports receiving research grants from Abbott Vascular, Bard Peripheral Vascular, Medtronic/Invatec, and Atrium; receiving consulting/advisory board fees from Abbott Vascular, Boston Scientific Corp, Complete Conference Management, Harvard Clinical Research Institute, Contego, Micell, and Becker Ventures; having equity in Lumen Biomedical, Medical Stimulation Corp, Angioguard (Cordis), and Micell; and serving on the board of directors for VIVA Physicians (501C3). Dr. Jaff reports that he is a noncompensated advisor to Abbott Vascular, Cordis Corporation, Covidien Vascular, Medtronic Vascular; received advisory board fees from Becker Venture Services, Bluegrass Vascular Therapies, Hansen Biomedical, Trivascular, and Vortex Medical; has equity interests in Access Closure, Embolitech, Hotspur, Icon Interventional, I.C. Sciences, Janacare, Northwind Medical, PQ Bypass, Primacea, Sadra Medical, Trireme, Vascular Therapies; and is a member of the board of directors of VIVA Physicians, a 501(c)3 education and research not-for-profit organization. Dr. Parikh receives research grants from Medtronic and CR Bard and is a consultant to Medtronic and Boston Scientific. Dr. Giri, Dr. Hawkins, Mr. Kennedy, Dr. I. Weinberg, and Dr. M. Weinberg have no relevant disclosures.

  • Jay Giri and Robert W. Yeh contributed equally to this work.


Background & Purpose

Embolic protection devices (EPD) may provide a mechanism to reduce peri-procedural strokes. They are advocated by consensus guidelines and mandated for Medicare reimbursement. However, outcomes data remain mixed. We aimed to characterize the population of patients undergoing unprotected carotid artery stenting (CAS) and assess the utility of distal filter EPD (F-EPD) in elective CAS.


We analyzed patients enrolled in the CARE Registry® undergoing CAS between May, 2005 and January, 2012. We assessed the relationship between distal F-EPD use versus no use (No-EPD) and the composite of in-hospital death or stroke (MAE) in unadjusted and 1:3 propensity-matched analyses.


Embolic protection was not attempted in a total of 579 out of 13,263 cases performed (4.4%). Patients in the No-EPD group had worse preprocedure neurologic risk factors including higher rates of acute evolving stroke, prior TIA/stroke, symptomatic lesion status, spontaneous carotid artery dissection, and use of general anesthesia intraprocedurally (all Standardized Differences{sd} >10). After exclusion of nonelective cases there was no significant difference in MAE between the No-EPD and F-EPD groups (1.6% vs. 2.3%, sd = 4.72). Additionally, after propensity matching, rates of MAE did not differ between the No-EPD (n = 355) and F-EPD (n = 1065) groups (1.7% vs. 2.5%, sd = 5.87).


Patients selected to undergo unprotected CAS in contemporary practice have high rates of adverse preprocedure neurologic risk factors. Our propensity-matched analysis did not demonstrate evidence of significant benefit or harm associated with use of F-EPD in elective CAS patients. © 2013 Wiley Periodicals, Inc.