Embolic protection: Assessing the options

Technological advances and the increasing operators of the experience allow to minimize the risk of cerebral embolic events after carotid artery stenting (CAS), making it a valuable alternative to carotid endo-atherectomy (CEA). The Achilles heel of this technique is that it can be complicated by cerebral embolism. The introduction of embolic protection devices (EPD) reduced the rate of procedure related cerebral embolic events and their use is recommended by available guidelines. Distal EPD (filter or occlusion balloons) and proximal EPD are currently available. Among distal EPDs, a theoretical advantage of filter as compared to occlusion balloons is the maintenance of antegrade flow during the procedure, minimizing the chances of acute hemispheric cerebral ischemia. As of today, the distal filter devices are the most commonly used EPDs for carotid stenting, some disadvantages of distal filters are possible embolization during lesion crossing or device retrieval, difficulty in navigating severely stenosed or tortuous vessels and spasm or dissection of the ICA. Proximal EPD carry the theoretical benefit of establishing embolic protection prior to any manipulation of the carotid lesion with wires, catheters or other devices, potential drawbacks of proximal EPDSs are patient intolerance to carotid occlusion. It has been suggested that proximal EPD could be particularly useful in symptomatic or thrombotic lesions.