Abstract 080: Challenges Associated with The Embolic Protection Device (epd) And Perioperative Events Between Those Who Did and Did Not Receive Epd During Carotid Artery Stenting
Authors: Lodi Y. M. , Reddy V. , Wang T. 
Published: January 2025

Background
In CREST trial 96.1% of the patient in carotid artery stenting (CAS) group had EPD and with a 4.1± 0.6 incidence of stroke. Despite the use of EPD, CAS has more cerebral ischemic events (CIE) compared to CEA. Additionally, the challenges associated with EPD device was not described and underreported. Objective of this study is to describe the challenges associated with EPD and compare the perioperative events between those with EP and without embolic protection. Additionally, to describe the unintentional strategies utilized for the EP.

Methods
From a prospectively maintained data base, Consecutive patient who underwent CAS for ≥ 70% stenosis based on NASCET criteria were collected and retrospectively analyzed from January 2012 to December 2020. Patients demographics, procedural techniques and perioperative events were captured. Outcome was measured using modified ranking scale (mRS). Our patients received acute loading doses of dual antiplatelets on the day prior to CAS.

Results
A total of 177 patients with baseline mRS 0.511±1.02 and 71% symptomatic, 29% asymptomatic underwent CAS in two community based tertiary care facilities. Patients received conscious sedation except one who underwent general anesthesia. Median age 69 (39‐91) female 39.55%. EPD was used in 69% and 41% didn't receive EPD due to the tortuosity or critical stenosis prevented DPD to cross the lesion. Stent couldn't be deployed in one because of non‐cooperation and underwent CEA. EPD associated challenges observed in 12 patients (9.8%). EPD couldn't be deployed in 3 required additional 3 devices and use of intraarterial eptifibatide (integrilin). EPD induced spasm developed in 5 required IA verapamil. Severe challenges were observed in 3 during retrieval of the capture device requiring multiple unintentional balloon angioplasties, patients head manipulations and IA intermittent delivery eptifibatide (5 mg at least 10 minutes interval maximum 2 doses). Unexpected EPD related events increased procedure time and have created significant stresses to the team and to the operators. Perioperative events without death, stroke and MI in 7 cases 3.9%. CEI in 2 cases (1.2%), one in an 88‐year‐old man without EPD and one in a 66‐year‐old man with EPD. Carotid artery asymptomatic dissection in one with EPD. Groin complications in 4 (2.3%). Anterior small hematoma in 3, had no impacts in hospital stay and outcomes. Closure device related femoral artery occlusion in 1, required emergent repair and achieved mRS 0. All asymptomatic patients achieved their baseline mRS and had no events. 30 days and 90 days mRS were 0.405 ±0.96 and 0.402 ± 0.95 respectively.

Conclusions
We observed significant challenges associated with EPD and unintentional interventions such as use of additional devices, vessels spasm, delivery of spasmolytic, balloon angioplasties and IA eptifibatide, especially during the retrieval of EPD. If the EPD couldn't be retrieved in our 3 cases, which might have potentially led to a life‐threatening stroke. We observed no added benefits in the prevention of embolic events between those who received or didn't receive EPD during CAS. A prospective randomized controlled trial is deemed necessary.