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Embolic Protection
T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Outcomes

          TERMINOLOGY

          • Synonyms

            • Cerebral protection device
          • Definitions

            • Embolic protection device (EPD): Intravascular device designed to prevent dislodged plaque/debris/embolic material from occluding distal vasculature
              • Used with interventions in various vascular beds
                • Internal carotid artery (ICA)/vertebral arteries
                • Coronary arteries/saphenous vein grafts
                • Renal arteries
                • Upper/lower extremity arteries
                • Venous interventions
              • 3 categories based on mechanism of action
                • Filter: Guidewire-mounted porous filtering device; deployed distal to target lesion
                  • Variable filter diameters permit optimal vessel apposition for capturing embolic debris
                  • Filter collapsed within delivery sheath while crossing target lesion
                  • Sheath retraction deploys filter within vessel
                  • After filter deployment, guidewire on which filter mounted becomes working guidewire
                • Distal occlusion: Balloon occlusion, positioned distal to lesion
                  • Early form of embolic protection; now infrequently used for ICA interventions
                  • Balloon occlusion catheters still used for embolic protection in other vascular beds
                  • May be used with liquid embolic agents to prevent nontarget embolization
                • Proximal flow blockage: Proximal occlusion of target artery using catheter-compatible sheath, with occlusion balloon at distal end (a.k.a. circulatory control device)
                  • Balloon inflated in common carotid artery (CCA) proximal to lesion
                  • Additional smaller occlusion balloon placed via sheath into external carotid artery (ECA)
                  • Can actively aspirate sheath; create flow reversal to prevent ICA emboli
                  • 1 proprietary design permits active flow reversal; central lumen of sheath connected via external filter into common femoral vein; creates temporary arteriovenous fistula
                  • Central lumen of sheath also permits guidewire/catheter/stent introduction

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      OUTCOMES

                      • Complications

                        • Expected Outcomes

                          Selected References

                          1. Kapadia SR et al: Protection against cerebral embolism during transcatheter aortic valve replacement. J Am Coll Cardiol. 69(4):367-377, 2017
                          2. Kassavin DS et al: An update on the role of proximal occlusion devices in carotid artery stenting. J Vasc Surg. 65(1):271-275, 2017
                          3. Kurzhals A et al: Efficiency test of current carotid embolic protection devices. Biomed Tech (Berl). ePub, 2017
                          4. Malas MB et al: Technical aspects of transcarotid artery revascularization using the ENROUTE transcarotid neuroprotection and stent system. J Vasc Surg. 65(3):916-920, 2017
                          5. Vos JA: Evidence overview: benefit of cerebral protection devices during carotid artery stenting. J Cardiovasc Surg (Torino). 58(2):170-177, 2017
                          6. Giustino G et al: Neurological outcomes with embolic protection devices in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis of randomized controlled trials. JACC Cardiovasc Interv. 9(20):2124-2133, 2016
                          7. Irani Z et al: The use of embolic protection device in lower extremity catheter-directed thrombolysis. Diagn Interv Imaging. 97(2):273-5, 2016
                          8. Omran J et al: Proximal balloon occlusion versus distal filter protection in carotid artery stenting: a meta-analysis and review of the literature. Catheter Cardiovasc Interv. ePub, 2016
                          9. Kwolek CJ et al: Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal. J Vasc Surg. 62(5):1227-34, 2015
                          10. Lookstein RA et al: Distal embolic protection for infrainguinal interventions: how to and when? Tech Vasc Interv Radiol. 13(1):54-8, 2010
                          11. Müller-Hülsbeck S et al: Embolic protection devices for peripheral application: wasteful or useful? J Endovasc Ther. 16 Suppl 1:I163-9, 2009
                          12. Cooper CJ et al: Embolic protection and platelet inhibition during renal artery stenting. Circulation. 117(21):2752-60, 2008
                          13. Divani AA et al: Microscopic and macroscopic evaluation of emboli captured during angioplasty and stent procedures in extracranial vertebral and internal carotid arteries. J Endovasc Ther. 15(3):263-9, 2008
                          14. Henry M et al: Embolic protection for renal artery stenting. J Cardiovasc Surg (Torino). 49(5):571-89, 2008
                          15. Kelso R et al: Flow reversal for cerebral protection in carotid artery stenting: a review. Perspect Vasc Surg Endovasc Ther. 20(3):282-90, 2008
                          16. Misra S et al: Embolic protection devices in patients with renal artery stenosis with chronic renal insufficiency: a clinical study. J Vasc Interv Radiol. 19(11):1639-45, 2008
                          17. Peterson BG: Embolic protection in infrainguinal interventions. Perspect Vasc Surg Endovasc Ther. 20(1):63-7, 2008
                          Related Anatomy
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                          Related Differential Diagnoses
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                          References
                          Tables

                          Tables

                          KEY FACTS

                          • Terminology

                            • Preprocedure

                              • Procedure

                                • Outcomes

                                  TERMINOLOGY

                                  • Synonyms

                                    • Cerebral protection device
                                  • Definitions

                                    • Embolic protection device (EPD): Intravascular device designed to prevent dislodged plaque/debris/embolic material from occluding distal vasculature
                                      • Used with interventions in various vascular beds
                                        • Internal carotid artery (ICA)/vertebral arteries
                                        • Coronary arteries/saphenous vein grafts
                                        • Renal arteries
                                        • Upper/lower extremity arteries
                                        • Venous interventions
                                      • 3 categories based on mechanism of action
                                        • Filter: Guidewire-mounted porous filtering device; deployed distal to target lesion
                                          • Variable filter diameters permit optimal vessel apposition for capturing embolic debris
                                          • Filter collapsed within delivery sheath while crossing target lesion
                                          • Sheath retraction deploys filter within vessel
                                          • After filter deployment, guidewire on which filter mounted becomes working guidewire
                                        • Distal occlusion: Balloon occlusion, positioned distal to lesion
                                          • Early form of embolic protection; now infrequently used for ICA interventions
                                          • Balloon occlusion catheters still used for embolic protection in other vascular beds
                                          • May be used with liquid embolic agents to prevent nontarget embolization
                                        • Proximal flow blockage: Proximal occlusion of target artery using catheter-compatible sheath, with occlusion balloon at distal end (a.k.a. circulatory control device)
                                          • Balloon inflated in common carotid artery (CCA) proximal to lesion
                                          • Additional smaller occlusion balloon placed via sheath into external carotid artery (ECA)
                                          • Can actively aspirate sheath; create flow reversal to prevent ICA emboli
                                          • 1 proprietary design permits active flow reversal; central lumen of sheath connected via external filter into common femoral vein; creates temporary arteriovenous fistula
                                          • Central lumen of sheath also permits guidewire/catheter/stent introduction

                                  PREPROCEDURE

                                  • Indications

                                    • Contraindications

                                      • Preprocedure Imaging

                                        • Getting Started

                                          PROCEDURE

                                          • Procedure Steps

                                            • Alternative Procedures/Therapies

                                              OUTCOMES

                                              • Complications

                                                • Expected Outcomes

                                                  Selected References

                                                  1. Kapadia SR et al: Protection against cerebral embolism during transcatheter aortic valve replacement. J Am Coll Cardiol. 69(4):367-377, 2017
                                                  2. Kassavin DS et al: An update on the role of proximal occlusion devices in carotid artery stenting. J Vasc Surg. 65(1):271-275, 2017
                                                  3. Kurzhals A et al: Efficiency test of current carotid embolic protection devices. Biomed Tech (Berl). ePub, 2017
                                                  4. Malas MB et al: Technical aspects of transcarotid artery revascularization using the ENROUTE transcarotid neuroprotection and stent system. J Vasc Surg. 65(3):916-920, 2017
                                                  5. Vos JA: Evidence overview: benefit of cerebral protection devices during carotid artery stenting. J Cardiovasc Surg (Torino). 58(2):170-177, 2017
                                                  6. Giustino G et al: Neurological outcomes with embolic protection devices in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis of randomized controlled trials. JACC Cardiovasc Interv. 9(20):2124-2133, 2016
                                                  7. Irani Z et al: The use of embolic protection device in lower extremity catheter-directed thrombolysis. Diagn Interv Imaging. 97(2):273-5, 2016
                                                  8. Omran J et al: Proximal balloon occlusion versus distal filter protection in carotid artery stenting: a meta-analysis and review of the literature. Catheter Cardiovasc Interv. ePub, 2016
                                                  9. Kwolek CJ et al: Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal. J Vasc Surg. 62(5):1227-34, 2015
                                                  10. Lookstein RA et al: Distal embolic protection for infrainguinal interventions: how to and when? Tech Vasc Interv Radiol. 13(1):54-8, 2010
                                                  11. Müller-Hülsbeck S et al: Embolic protection devices for peripheral application: wasteful or useful? J Endovasc Ther. 16 Suppl 1:I163-9, 2009
                                                  12. Cooper CJ et al: Embolic protection and platelet inhibition during renal artery stenting. Circulation. 117(21):2752-60, 2008
                                                  13. Divani AA et al: Microscopic and macroscopic evaluation of emboli captured during angioplasty and stent procedures in extracranial vertebral and internal carotid arteries. J Endovasc Ther. 15(3):263-9, 2008
                                                  14. Henry M et al: Embolic protection for renal artery stenting. J Cardiovasc Surg (Torino). 49(5):571-89, 2008
                                                  15. Kelso R et al: Flow reversal for cerebral protection in carotid artery stenting: a review. Perspect Vasc Surg Endovasc Ther. 20(3):282-90, 2008
                                                  16. Misra S et al: Embolic protection devices in patients with renal artery stenosis with chronic renal insufficiency: a clinical study. J Vasc Interv Radiol. 19(11):1639-45, 2008
                                                  17. Peterson BG: Embolic protection in infrainguinal interventions. Perspect Vasc Surg Endovasc Ther. 20(1):63-7, 2008