Embolic Protection Issues

The last two decades have seen significant advances in therapies for neurovascular ischemic disease and carotid artery disease. With carotid artery stenting becoming increasingly more routine and available, understanding the risk and benefit profiles for that approach in comparison with carotid endarterectomy is important. Embolic protection devices including filters and flow reversal devices, as used in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial, Carotid Revascularization Endarterectomy versus Stent Trial (CREST), and the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) trial, have made carotid artery stenting a safer therapy. In addition, managing in-stent stenosis has become a separate challenge, requiring embolic protection. A discussion of the combination of distal and proximal protection is crucial to understanding the safest approach to treating carotid disease based on a patient’s anatomy. Understanding the risk profiles, potential complications, and salvage maneuvers is important for any surgeon managing carotid disease.