Operator’s Experience Is the Most Efficient Embolic Protection Device for Carotid Artery Stenting

Carotid artery stenting (CAS) is a reputable and safe alternative therapeutic option to surgical endarterectomy for treatment of obstructive extracranial carotid atherosclerosis.1 Because of the routine use of cerebral embolic protection devices (EPDs), post-CAS neurological complications have decreased substantially during the past years, and it is now accepted that the use of EPDs abates postprocedural stroke risk.1Article see p 552It has been speculated that a proximal EPD may offer more efficient neuroprotection because it is active before target lesion crossing, whereas distal EPDs must cross the lesion to establish neuroprotection.2As of today, because of the small incidence of post-CAS neurological events, it is difficult to prove the superiority of one EPD compared with another on the basis of the ability to reduce clinically relevant neurological events.Diffusion-weighted MRI (DW-MRI) is the most sensitive method to diagnose brain infarction at the early phase and is a major improvement compared with computed tomography.3,4The use of DW-MRI has disclosed that besides clinically apparent postprocedural strokes, CAS, as any other cardiovascular intervention, is associated with the occurrence of new small clinically silent brain lesions on post-treatment DW-MRI.5 In past years, DW-MRI lesions have been valued as surrogate markers of brain embolism to evaluate the relative efficacy of EPDs.In this issue of Circulation: Cardiovascular Interventions , de Castro-Afonso et al6 reported the results of a single center trial in which the authors evaluated the relative efficacy of proximal (n=21) and distal EPD (n=19) for CAS. They reported a significant reduction in the incidence (15.8% versus 47.6%; P =0.03), …