Proximal versus distal embolic protection for carotid artery stenting: a national cardiovascular data registry analysis

JACC Cardiovasc Interv. 2015 Apr 20;8(4):609-15. doi: 10.1016/j.jcin.2015.02.001.


Objectives: The aim of this study was to compare the stroke/death rates between proximal embolic protection devices (P-EPDs) and distal filter embolic protection devices (F-EPDs) in elective carotid artery stenting (CAS).

Background: P-EPDs have theoretical advantages that may make them superior to F-EPDs for stroke prevention during CAS.

Methods: We examined 10,246 consecutive elective CAS procedures performed with embolic protection in the NCDR CARE registry between January 2009 and March 2013. We analyzed crude and propensity-matched rates of in-hospital combined death/stroke in patients treated with P-EPDs versus F-EPDs. Secondary analyses included 30-day adverse event rates and stroke rates by the involved cerebrovascular territory.

Results: P-EPDs were used in 590 of 10,246 cases (5.8%). Patients treated with P-EPDs had higher rates of symptomatic lesion status (46.8% vs. 39.7%, p<0.001), atrial fibrillation/flutter (16.1% vs. 13.0%, p=0.03), and history of a neurological event (51.2% vs. 46.6%, p=0.03). In unadjusted and propensity-matched analyses, differences in in-hospital stroke/death between P-EPD and F-EPD cohorts were nonsignificant (1.5% vs. 2.4%, p=0.16 and 1.6% vs. 2.0%, p=0.56, respectively). For patients with available data (n=7,693, 75.1%), 30-day adverse events rates were similar for P-EPDs and F-EPDs before (2.5% vs. 4.2%, p=0.07) and after (2.7% vs. 4.0%, p=0.22) propensity matching.

Conclusions: Use of a P-EPD during CAS was associated with low rates of in-hospital stroke/death similar to those with an F-EPD in the first comparative effectiveness study of the devices. An adequately powered randomized trial comparing clinical outcomes between these devices is unlikely to be feasible.

Keywords: carotid artery stenosis; carotid artery stenting; embolic protection devices; stroke.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Aged, 80 and over
  • Angioplasty / adverse effects
  • Angioplasty / methods*
  • Angioplasty / mortality
  • Carotid Stenosis / diagnostic imaging
  • Carotid Stenosis / mortality
  • Carotid Stenosis / therapy*
  • Cause of Death
  • Cohort Studies
  • Embolic Protection Devices / statistics & numerical data*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Propensity Score
  • Registries*
  • Retrospective Studies
  • Risk Assessment
  • Severity of Illness Index
  • Sex Factors
  • Statistics as Topic
  • Stents*
  • Stroke / mortality
  • Stroke / prevention & control*
  • Survival Rate
  • Treatment Outcome
  • Ultrasonography, Doppler
  • United States