Carotid angioplasty in a pulsatile flow model: Factors affecting embolic potential

Objectives: carotid endoluminal intervention is an alternative to surgery but carries a risk of embolic stroke even with distal protection devices. We investigated the clinical features and degree of stenosis related to number and size of emboli during carotid angioplasty. Design: an experimental ex vivo study. Materials: an ex vivo pulsatile flow model was used in which temperature, velocity, flow, pressure and viscosity characteristics were designed to simulate the carotid circulation. Methods: carotid endarterectomy specimens excised as intact cylinders (n = 28) were subjected to a standardised angioplasty procedure using radiological guidance. Emboli collected in filters placed distally were counted and sized using microscopy. Results: median number of emboli during angioplasty was 133 (range 15-1331). Median size of the largest embolus was 700 microns (range 75-2400). Severity of stenosis correlated with increased maximum size (r = 0.55, p = 0.012). Statin therapy > 4 weeks pre-operatively was associated with reduced emboli number and size (54 (range 15-748) vs 247 (range 37-1331) [p = 0.023] and 400 mum (range 75-2400) vs 1300 mum (range 600-2200) [p - 0.022]). Conclusions: in this model a wide range of emboli number and size were produced. Number and size of embolic particles were highest in patients with high-grade stenoses not receiving statin therapy.