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Slow-Flow Phenomenon During Carotid Artery Intervention With Embolic Protection Devices

Predictors and Clinical Outcome

Ivan P. Casserly, MB, BCh^_*, Alex Abou-Chebl, MD, Robert B. Fathi, MD, PhD, David S. Lee, MD, Jacqueline Saw, MD, Jose E. Exaire, MD, Samir R. Kapadia, MD, Christopher T. Bajzer, MD and Jay S. Yadav, MD^,_*

^_* Denver Veterans Affairs Medical Center and University of Colorado Health Sciences Center, Denver, Colorado
Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
Vancouver General Hospital, Vancouver, Canada
National Institute of Health, Mexico City, Mexico

View larger version (120K): [in a new window]   Figure 1 Characteristic angiographic appearance of slow-flow (A and B) and no-flow (C) in the internal carotid artery (ICA) during carotid intervention with emboli protection devices (EPD). (A) Complete column of contrast in ICA with mild reduction in antegrade flow compared with the external carotid artery (ECA). (B) Marked reduction in antegrade flow in the ICA with incomplete filling of the lumen, but contrast does flow beyond the EPD. In C, there is no antegrade flow beyond the origin of the ICA (arrow). CCA = common carotid artery.

View larger version (61K): [in a new window]   Figure 2 Schematic of proposed mechanism of slow-flow and rationale for aspiration prior to retrieval of filter. (A) Carotid bifurcation lesion with filter placed in the distal internal carotid artery (ICA). (B and C) Balloon angioplasty and stenting results in distal embolization of debris from atherosclerotic plaque causing occlusion of filter pores and accumulation of debris in stagnant column of blood proximal to the filter. (D and E) Aspiration proximal to the filter removes the debris from the stagnant column of blood without affecting the debris causing occlusion of the filter. CCA = common carotid artery.

View larger version (12K): [in a new window]   Figure 3 Thirty-day incidence of stroke, death, and myocardial infarction (MI) in patients with slow-flow and normal flow.

View larger version (13K): [in a new window]   Figure 4 Kaplan-Meier estimate of survival free of stroke or death among patients with slow-flow or normal flow during carotid intervention.

View larger version (120K): [in a new window]   Figure 5 Magnetic resonance image from brain of patient with slow-flow during carotid intervention and post-procedural stroke. Image demonstrates numerous punctate foci of restricted diffusion involving the right frontal and parietal cortex (indicated by arrows).

View larger version (52K): [in a new window]   Figure 6 Histopathological appearance of debris aspirated from the column of blood proximal to the filter during an episode of slow-flow. (A) Numerous amorphous lipoid masses (open arrow) and chronic inflammatory cells (arrow). (B) Cholesterol crystal (arrow). (C) Multiple spindle-shaped cells consistent with the appearance of smooth muscle cells.