Micro-mesh stents and sustained anti-embolic action to reduce cerebral embolisation may contribute to solving the remaining limitations of carotid stenting, according to Alberto Cremonesi (Cotignola, Italy), who spoke at CX 2015 (28 April–1 May, London, UK).

Cremonesi examined the potential for micro-mesh stents to improve existing carotid artery stenting outcomes.

He told delegates that the correct technique for performing a carotid artery stenting was to conduct a pre-procedural evaluation for common carotid engagement, to select the correct stent and to select and manage an embolic protection device.

Cremonesi said that it is already known that “not all plaques are the same”, and that “carotid artery stenting and carotid endarterectomy are —and will remain—emboli-generating procedures”. He told the audience that it is possible to give sustained anti-embolic over time using specific stents.

When a poorly-selected stent is used for carotid artery stenting, intra-strut prolapse can occur resulting in post-procedural embolic events. The difficulty then, commented Cremonesi, is that “lesions in the carotid arteries are often anatomically and morphologically very challenging. For this reason, plaque coverage can play an important role.”

The use of stenting strategies such as open cell, closed cell and hybrid geometry can be considered “time honoured”. Now, vascular specialists have access micro-mesh double layer carotid stents (Terumo, InspireMD and Gore), said Cremonesi, whose personal experience is with the Roadsaver carotid stent from Terumo.

Cremonesi admitted that “In terms of data, we do not have very much at the moment” for the use of micro-mesh. Some data do exist from the CARENET all-comer trial, in which 30 patients saw “very good” outcomes without any neurological events up to five months follow-up. A further multicentre trial with 100 patients, CLEAR-ROAD, is also beginning, though Cremonesi said that he did “not want to conclude anything” about it yet.

“We are probably changing the paradigms in carotid artery stenting, because with these micro-mesh stents and their sustained anti-embolic action, we can solve the remaining limitation of carotid stenting,” ended Cremonesi.

Discussing his presentation with the audience, Cremonesi mentioned that “two-thirds of the embolic complications are in the post-procedural phase.” When session chairman Roger Greenhalgh asked about the cause for this later onset of complications, Cremonesi told him that it was due to the stent interacting with and cutting the plaque in the carotid artery, which can occur during the phase and even up to 48 hours later. Cremonesi made it clear that this problem is one of the carotid artery, rather than one associated with the aortic arch.