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CarotidArteryStentingUnderNeuroprotectionDevice Carotidarterystenosis AtheroscleroticplaqueformationatcarotidbifurcationPlaqueulceration thrombusformation anddistalembolismisthemajormechanismcausingsymptomsCarotidstenting CS hasbeenreportedsince1987asanalternativetoendarterectomyHowever unprotectedCScarries5 10 riskofproceduralstroke PaulHLKao Proceduralembolism ThemostcommonmechanismforproceduralstrokeEmbolicmaterialscanbereleasedinallstepsduringCSinalmosteverycaseParticlesobstructingcriticalvesselsresultinsymptoms butmayalsobesilentwithunknownlong termeffectEmbolicprotectiondevice EPD maythereforebemandatoryinCS PaulHLKao SymptomaticrightICAS PaulHLKao SymptomaticrightICAS LeftarmweaknessduringprocedurePlainCT3hrpoststenting PlainCT2dayspoststenting PaulHLKao Idealprotectiondevice CompleteinterceptionoftheemboliMaintaincerebralperfusionGoodhandlingcharacteristicsIntuitiveandcompatiblewithexistingprocedureandequipmentNosizinglimitationSafeandeffectiveinclinicalstudiesBut IDEALEPDisnon existingintherealworld PaulHLKao PartiallistofcurrentEPD ProximalocclusionInvatecMoMAArteriAPAESVelocimedProxisDistalocclusionMedtronic PercuSurgeGuardWirePlusKenseyNashTriActivRubiconMedicalGuardianMeshfilterMedtronic AVEMDTInterceptorMicrovenaTRAPEv3SPIDER SupportedmembranefilterAbott MednovaEmboshieldCordisAngioguardXPGuidantAccunetSCIONSCIProUnsupportedmembranefilterBSCFilterWireEX EZMetamorphicE Sack E TrapIntraTherapeuticsSulzer IntraguardRubiconFilter PaulHLKao Distalocclusion Balloon tippedwirecrosseslesionInflationbeforeangioplastytostopanterogradeflowDebrisreleasedstayedinthestagnantcolumnofbloodAspirationtoremovedebris PaulHLKao Advantageanddrawback BettercrossingprofilethanotherdistaldevicesOnesizefitsall 3 6mm EmbolicparticlesizeirrelevantLesionhastobecrossedfirstPatienttoleranceTimepressureontheoperatorPotentialdistalICAtrauma Distalfilter FiltercrossesthelesionFilterdeployedbeforeangioplastyAnterogradeflowmaintainedwhiledebrisreleasedstoppedbythefilterFinalretrievalofthefilterwiththetrappeddebris PaulHLKao Advantageanddrawback AnterogradeICAflowusuallymaintainedwithbetterpatienttoleranceLesstimepressureontheoperatorContrastcontrolispossibleforlesionvisualizationLesionhastobecrossedfirstBulkierandmorerigidincrossingtightandtortuousstenosisPotentialdistalICAtraumaEmbolicparticlessmallerthanporesizeescapefiltration Proximalocclusion OcclusionoftheCCAbeforelesionmanipulationAnterogradeflowstoppedordeminishedFurtherocclusionoftheECAmaybedonetocreatetotalflowterminationDebrisreleasedduringinterventionmayberemovedbyaspirationorartificialretrogradeflow PaulHLKao Advantageanddrawback ProtectionstartsbeforeICAlesionistouchedVirtuallynosizelimitonthetargetICAChoiceofanywire balloon andstentLargegroinaccessPatienttoleranceTimepressureontheoperator PaulHLKao PercuSurgeGuardWirePlussystem GuardWiretemporaryocclusionwireMicrosealportEZ flatorinflationdeviceExportaspirationcatheter PaulHLKao LICAstentingwithGuardWirePlus PaulHLKao AngioguardXP Nitinolfilterbasketwithsiliconmembrane poresize100micron DeliverysheathRetrievalsheath PaulHLKao RICAstentingwithAngioguardXP PaulHLKao RICAstentingwithAngioguardXPAngioguardXP PaulHLKao FilterWireEX Fishnetpolyurethanefiltermembrane poresize80micron withNitinolmouthloopSamemonorailsheathfordeliveryandcapture PaulHLKao RICAstentingwithFilterWireEX PaulHLKao RICAstentingwithFilterWireEX PaulHLKao RICAstentingwithFilterWireEX PaulHLKao Emboshield Special0 014 wirewithdistal0 018 segmentFloatingfilterwithpolyurethanefiltermembrane poresize150micron andnitinolbasketframworkDeliverysheathCapturesheath PaulHLKao LICAstentingwithEmboshield PaulHLKao LICAstentingwithEmboshield PaulHLKao MoMA 10Frballoon neckedcatheterforCCAocclusionExtensionballoonforECAocclusionCatheterlumenservesasworkingchannelforregularstentingequipments PaulHLKao LICAstentingwithMoMA PaulHLKao LICAstentingwithMoMA PaulHLKao LICAstentingwithMoMA PaulHLKao NTUHexperience demographics PaulHLKao NTUHexperience clinical PaulHLKao NTUHcriteriaforEPDchoice PaulHLKao Conclusion Proceduralembolism maybeclinicallysilent isuniversalinCSActiveembolicprotectioncanbeeffectiveachievedbyvariousdevicesInterventionistmustunderstanddevicedesignsandcharacteristicstofacilitateequipmentchoiceLackingdirectcomparisonbetweenCSwithorwithoutprotection theaccumulatingclinicalevidencesuggestthatuseofprotectionshouldbethestandardpractice PaulHLKao ThankYouForYourAttention Evidencesforproceduralembolism J Theronreported600 1300microncholesterolcrystalsin17of21samplescollectedduringCST Ohkireportedparticlesfrom50to 1000micronreleasedinallstepsofCSusinghumancarotidplaquespecimenW Jordanshowedaveraging74embolidetectedbyTCDduringCSprocedureK Mathiasshowednewclinicalsilentsignal intenselesionsbyMRIin28 5 ofunprotectedCSM HenryinaPercuSurgeaspirateanalysisreportedparticlesinallCSprocedures PaulHLKao Preventionofembolism PassiveAdjuvantpharmacologyRefinedproceduraltechniqueDedicateddevicesdesignedforCSActiveEmbolicprotectiondevices PaulHLKao Terminologyandclassification PaulHLKao PaulHLKao PaulHLKao Comparisonofdifferentdevices DistalLesionhastobecrossedfirstSmallerdeviceprofileOcclusionPerfusionistemporarilyStoppedCompleteinterceptionofdebris ProximalProtectionstartedbeforecrossinglesionLargevascularaccessinevitableFilterPerfusionmaintainedParticlessmallerthanporesizeescaped PaulHLKao Comparisonofdifferentdevices PaulHLKao Isitreallyworthyofthehassle DowereallyneedprotectioninCS VastevidencesforembolireleaseduringCSSeveralsinglecenterexperiencesSinglecenterhistoricalcomparisonunprotectedprotectedM Amor M Henry4 9 9 182 2 7 8 268 K Mathias3 8 46 1222 2 9 17 577 Bottomlineis wedon thaverandomizedprospectivecomparisonres
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