Percutaneous insertion of a cerebral protection device to prevent cerebral embolism during TAVI

Evidence-based recommendations on percutaneous insertion of a cerebral protection device to prevent cerebral embolism during TAVI in adults. This involves placing a device inside an artery near the heart.

# Recommendations
The evidence on percutaneous insertion of a cerebral protection device to prevent cerebral embolism during transcatheter aortic valve implantation (TAVI) raises no major safety concerns other than those associated with the TAVI procedure. However, the evidence on efficacy for preventing TAVI-related stroke is inconclusive. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wishing to do percutaneous insertion of a cerebral protection device to prevent cerebral embolism during TAVI should:
Inform the clinical governance leads in their NHS trusts.
Ensure that patients and their carers understand the procedure's safety and efficacy, as well as any uncertainties about these. Provide them with clear written information to support shared decision making. In addition, the use of NICE's information for the public is recommended.
Details of all patients should be entered into the UK TAVI registry.
Patient selection for this procedure should be done by the multidisciplinary team that is considering the suitability of TAVI.
This procedure should only be done in specialised centres, and only by clinicians and teams with specific training and experience in complex endovascular interventions. Centres doing this procedure should have both cardiac and vascular surgical support for the emergency treatment of complications and subsequent patient care.
NICE encourages further research on percutaneous insertion of a cerebral protection device to prevent cerebral embolism during TAVI. This should include details of patient selection and risk stratification for TAVI-related stroke. NICE may update the guidance on publication of further evidence.# The condition and procedure

# The condition
Transcatheter aortic valve implantation (TAVI) aims to provide a less invasive alternative to open cardiac surgery for treating aortic stenosis, avoiding the need for sternotomy and cardiopulmonary bypass. However, debris may be dislodged during the TAVI procedure. This can enter the cerebral circulation and embolise, causing cerebral ischaemic events including a stroke.

# The procedure
Percutaneous insertion of a cerebral protection device aims to prevent debris dislodged during TAVI from passing into the cerebral circulation. The aim is to reduce the risk of cerebral ischaemic events including a stroke.
During the TAVI procedure, before the valve is inserted, a cerebral protection device is inserted percutaneously through the radial or femoral artery. Depending on the type of device used, it is placed into the aortic arch or into the brachiocephalic (innominate) and left common carotid arteries. It is deployed to protect the ostia of the brachiocephalic (innominate) artery and the left common carotid artery. It may also protect the left subclavian artery, depending on the type of device used. It works either by filtering dislodged debris from the blood, or by deflecting dislodged debris away from the cerebral circulation to the systemic circulation. The device is removed at the end of the TAVI procedure.
The evidence review identified 3 types of cerebral protection devices. One is a deflector system that covers all 3 main branches of the aortic arch. The 2 other types cover the brachiocephalic trunk and the left common carotid artery; 1 is a filter system, the other is a deflector system.