Filter content after carotid angioplasty and stenting: Relation to ischemic lesions in diffusion-weighted imaging

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Piñero González de la Peña, A. González García, F. Moniche Álvarez, A. Mayol Deyá, J.R. González Marcos, A. Cayuela Domínguez, A. Gil Peralta" "autores" => array:7 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Piñero González de la Peña" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "González García" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Moniche Álvarez" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Mayol Deyá" ] 4 => array:2 [ "nombre" => "J.R." "apellidos" => "González Marcos" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Cayuela Domínguez" ] 6 => array:2 [ "nombre" => "A." 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(A) Photograph of the prototype. (B) MR image of the PD sequence (120/4/20°) (TR/TE/Flip angle). (C) MR image of the T2 sequence (120/14/20°). (1) Solution containing no iron. (2) Solution containing 0.3mgFe/mL. (3) Solution containing 0.5mgFe/mL. (4) Solution containing 0.6mgFe/mL. (5) Solution containing 1.2mgFe/mL. (a) Copper sulfate CuSO4−. (b) Water. The signal from the tube containing no iron (solution 1) is used as the reference to calculate the ratio in a way similar to that of the muscle used in real patients. The signal intensity ratio of solutions 2 and 3 is similar to the average ratios of patients with moderate iron overload for the PD and T2 sequences. The ratios of solutions 4 and 5 are similar to the average ratios of patients with high iron overload. Coppers sulfate provides great signal intensity to the phantom, stable, facilitating its handling in the MRI systems. The water surrounding the tubes helps prevent paramagnetic susceptibility artifacts." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Alústiza, J.I. Emparanza, P. Aldazábal, A. Garrido, N. García, E. Salvador, M. San Vicente" "autores" => array:8 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Alústiza" ] 1 => array:2 [ "nombre" => "J.I." "apellidos" => "Emparanza" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Aldazábal" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Garrido" ] 4 => array:2 [ "nombre" => "N." "apellidos" => "García" ] 5 => array:2 [ "nombre" => "E." "apellidos" => "Salvador" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "San Vicente" ] 7 => array:1 [ "colaborador" => "Grupo Burnia" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833811000750" "doi" => "10.1016/j.rx.2010.12.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833811000750?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510712000742?idApp=UINPBA00004N" "url" => "/21735107/0000005400000002/v1_201305061448/S2173510712000742/v1_201305061448/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "Original Report" "titulo" => "Filter content after carotid angioplasty and stenting: Relation to ischemic lesions in diffusion-weighted imaging" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "155" "paginaFinal" => "164" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Piñero González de la Peña, A. González García, F. Moniche Álvarez, A. Mayol Deyá, J.R. González Marcos, A. Cayuela Domínguez, A. Gil Peralta" "autores" => array:7 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Piñero González de la Peña" "email" => array:1 [ 0 => "pilar.pinero.sspa@juntadeandalucia.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "González García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Moniche Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Mayol Deyá" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "J.R." "apellidos" => "González Marcos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Cayuela Domínguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "A." "apellidos" => "Gil Peralta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad de Neurorradiología Diagnóstica, Servicio de Radiodiagnóstico, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Neurorradiología Intervencionista, Unidad de Gestión Clínica de Radiodiagnóstico, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neurología, Unidad de Gestión Clínica de Neurociencias, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Documentación Clínica y Estadística, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Contenido en filtros tras angioplastia y colocación de stent carotídeo: relación con lesiones isquémicas en la resonancia magnética de difusión" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1287 "Ancho" => 1833 "Tamanyo" => 424494 ] ] "descripcion" => array:1 [ "en" => "Electron microphotograph of the 3 main components found in the filters: platelet aggregates (A), cellular debris (B), and cholesterol crystals (C). (Lead citrate and uranyl acetate, original magnification, 25,000×.)" ] ] ] "textoCompleto" => "IntroductionCAS is now considered an effective and safe alternative to endarterectomy (EC) for the treatment of patients with symptomatic atherosclerotic disease of the ICA, when the stenosis is >70% assessed by noninvasive imaging or >50% by angiography, provided that they are at low or average risk of complications associated with endovascular procedures, as recently indicated by the recommendations of the American Heart Associations (AHA) and the American Stroke Association (ASA) (Class I recommendation with level B evidence).<a class="elsevierStyleCrossRef" href="#bib0005">1</a> This confirms what landmark trials and studies have already demonstrated.<a class="elsevierStyleCrossRefs" href="#bib0010">2–4</a> The development of protection devices stems from the demonstration that CAS results in a larger number of atherosclerotic fragments dislodged from the arterial wall that may embolize distally than in EC,<a class="elsevierStyleCrossRef" href="#bib0025">5</a> carrying a greater risk of cerebral ischemia. In spite of the great enthusiasm generated by these devices, release of microemboli is practically a constant feature during CAS, as studies based on transcranial Doppler (TCD) ultrasound or DWI<a class="elsevierStyleCrossRefs" href="#bib0030">6–8</a> have demonstrated.Recently, the natural history of the atherosclerotic plaque has aroused an interest that has helped define factors of plaque vulnerability that are directly involved in the development of cerebral ischemic complications.<a class="elsevierStyleCrossRefs" href="#bib0045">9–11</a>The systematic use by our team of distal protection filters during CAS has allowed direct access to the material dislodged during the procedure for its evaluation.In addition, the availability of DWI has made this technique a fast and efficient tool for the detection of ischemic lesions associated with CAS. The combination of these two facts represents the foundation of the questions before us, which constitute the objective of this study: Does the occurrence of ischemic lesions after CAS correlate with the presence of material in distal protection filters? If this were the case, is the number and/or size of lesions associated with the amount and/or composition of the material retrieved from the filters? Moreover, which variables (demographic, clinical and procedural) increase the release of emboli of a specific nature?Material and methodsDesign of the study and study populationThis study is the result of a retrospective analysis of data obtained from a subset of patients included in a previous prospective study<a class="elsevierStyleCrossRef" href="#bib0060">12</a> with a larger sample size. The content of the filters was submitted for histologic analysis, recording the volume and composition of the material retrieved after performing CAS with placement of distal protection devices for the treatment of patients with high-grade ICA stenosis according to the NASCET criteria.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Between July 2003 and January 2005, 76 patients (60 men [78.9%]; mean age, 68.39 years [range 46–82]) in whom pre- and post-procedural DWI studies were available were evaluated. Inclusion and exclusion criteria have been described elsewhere.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Before CAS, neurologic examination and recording of demographic data, and vascular risk factors were performed by three neurologists (FM, JRGM, AGP) with experience in cerebrovascular disease and who classified patients according to the NIHSS.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>The study complies with the Declaration of Helsinki and was approved by our institutional review board. Written consent for the procedure and related tests was obtained from all patients.Neurointerventional procedureAll procedures were performed by two interventional neuroradiologists (AG, AM) with extensive experience in endovascular treatment of carotid disease. Briefly, the procedure involved the placement—using the femoral approach and after local anesthesia—of a 6F long sheath catheter (90cm) in the common carotid artery (CCA). The filters were deployed crossing the stenosis through the catheter. Four types of filters were used: EPI and EZ FilterWires (Boston Scientific/Target Therapeutics, Fremont, CA), Spider (ev3, Plymouth, MN), and Accunet (Guidant, Santa Clara, CA), with an 80–130μm pore size. Once the filter was placed and expanded, a predilation of the stenosis with a low-profile balloon (2–3cm) was performed in all patients, and a self-expandable stent was placed in the stenotic segment (Carotid Wallstent [CWS], Boston Scientific/Target Therapeutics, or carotid Acculink, Guidant). When needed, postdilation was performed with a 5–6mm balloon catheter.Patients were on antiplatelet therapy (125mg/day aspirin and 75mg/day clopidogrel) at least for 3 days and on anticoagulant therapy (unfractionated IV heparin) for 48h before CAS. Hemodynamic and electroencephalographic (EEG) changes were monitored during the procedures, and episodes of hypotension, bradycardia, asystole, and syncope were recorded. Before arterial catheterization, a dose of heparin required to maintain the activated clotting time (ACT) between 250 and 300s was administered. Patients were discharged on clopidogrel (75mg/day) for a month and aspirin (125mg/day) or triflusal (600mg/day) permanently. Clinical examination was performed in all patients with a Doppler ultrasound of supra-aortic branches after 1, 3, 6 and 12 months after CAS.The 30-day morbidity and mortality were registered (transient ischemic attack [TIA], minor and major stroke, acute myocardial infarction [AMI] and death).Histopathologic examination of the filtersAn experienced neuropathologist (ER) examined all filters after retrieval. The filters were removed from the guidewire, cut open along the long axis, and examined under optical microscope. The particles were removed from the filter by using microforceps, fixed in paraformaldehyde, embedded in EPON (Resolution Performance Products, Houston, TX), cut into thin sections, stained with lead citrate, and examined under an electron microscope. Photographs of the filters after removal from the guidewire were taken before and after being cut open (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>A semiquantitative analysis of the embolic material removed from the filters was performed. A sample was considered to have a maximal load when the volume was >10 lambdas (1λ=0.001ml=1mm3), moderate when the volume was >1λ, and minimal when it was <1λ (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Magnetic resonante techniqueAll patients underwent a complete MR examination in the three days before CAS and DWI 24h after the procedure on a 1.5 T MRI system (Intera, Philips Medical Systems, Best, The Netherlands) with a brain coil. Pre-CAS protocol included axial and sagittal T1-weighted spin echo sequences (TR/TE, 539/13; 2 excitations), axial T2/proton density (3402/8–110), field echo-echo planar (1460/23; flip angle, 20°), coronal FLAIR (8000/120; TI, 2200) sequences, and 3D MR angiography of supra-aortic branches after administration of contrast agent (slab thickness 60mm, 60 sections). A bolus of gadopentetate dimeglumine (Magnevist®) was injected at a flow rate of 2.5ml/s, followed by a 30ml saline flush using an MR compatible injector system (Spectris; Medrad, Pittsburgh, PA).DWI was obtained with a spin-echo echo-planar sequence (3562/95; echo-planar imaging factor, 77; section thickness, 6.0mm; intersection gap, 1mm), with b values of 0 and 1000mm2/s, with the latter value applied in each of the three main gradient directions (x, y, z). Apparent diffusion coefficient (ADC) maps were obtained in all patients.Imaging analysisA neuroradiologist (PP) blinded to patient and procedural characteristics evaluated the MR images. In the pre-CAS MR examinations, the presence of atrophy, leukoaraiosis, lacunar lesions, and brain infarct, as described elsewhere in the literature, were recorded.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> On the DWI sequence, the presence of acute ischemic lesions (defined as lesions with conspicuous hyperintensity on the diffusion sequence with a b value=1000, and hypointensity on the ADC map) was evaluated. These findings were compared with presence of new ischemic lesions, their number and size (<5mm, 5–10mm, >10mm in the transverse axis), distribution (cortical, subcortical, deep), and anatomic and vascular location on post-procedural DWI.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>Statistical analysisData were analyzed by an expert (AC) with the software package SPSS (SPSS 15.0, Chicago, IL). Qualitative variables were expressed as relative and absolute frequencies, and quantitative variables, as the median and standard deviation. A bivariate analysis was performed with the chi-square test to correlate the volume and characteristics of the particles retrieved from the filter with the presence of new ischemic lesions on postprocedural DWI. The chi-square test (for qualitative variables) and the Student's t-test or the ANOVA test (for quantitative dependent variables and dichotomies or >2 categories of independent variables, respectively) were used to correlate a number of demographic variables, vascular risk factors, periprocedural hemodynamic complications or morbidity and mortality after CAS with the presence of new ischemic lesions on DWI and with the volume and characteristics of the particles. A p value <.05 was considered statistically significant.ResultsA total of 76 ICA were treated in 76 patients. Demographic and angiographic characteristics are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>. Vascular risk factors were common, especially hypertension (78.9%) and hypelipidemia (56.6%).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Symptomatic patients (76.3%) underwent the procedure at least four weeks after the schemic attack, but in 5 patients (6.6%) it was performed on an emergency basis.A distal filter was used in all patients; the distribution by type of filter was as follows: EZ in 39 patients (51.3%), EPI in 14 (18.4%), Spider in 14 (18.4%), and Accunet in 9 (11. 8%). In 56 patients (73.7%), ≤2 dilations were required before stent placement. In the remaining 20 patients (26.3%), ≥3 dilations were needed. During the procedure vasospasm occurred in 22 cases and dissection of the intima occurred in 5 cases, without relevant clinical consequences. A total of 76 stents were placed (in one patient, 2 stents were used and other patient underwent angioplasty without stent placement): CWS were placed in 43 (56.6%), and Acculink in 33 (43.4%).Transient hemodynamic complications were as follows: syncope in 19 patients (25%), bradycardia in 40 (52.6%), hypotension in 33 (43.4%) and asystole in 21 (27.6%).After CAS, 3 patients (3.9%) developed TIA, lasting less than 15min. No major, minor stroke or AMI occurred in the 30-day period following the procedure.Before CAS, DWI showed acute focal ischemic lesions in 9 patients (11.8%). Twenty-nine lesions were detected. In 5 patients, the lesions were multiple (4 patients with 4 lesions and 1 with 8). After CAS, DWI showed 27 lesions in 12 patients (15.8%). There were 6 patients with a single lesion; 1 patient with 2 lesions; 3 patients with 3 lesions; 1 with 4 lesions, and other patient with 6 lesions. In 10 of them (83.3% of the patients with lesions after CAS), the lesions were located in the territory ipsilateral to the treated artery. There was 1 patient (1.3%) with lesions in the posterior fossa and other patient with lesions in posterior fossa and in the territory contralateral to the treated ICA. The lesions were in a cortical location in 5 patients (41.7%), cortical–subcortical in 3 patients, in deep white matter in 2, subcortical in 1 patient, and in 1 patient in a border zone. As for brain location, lesions were in a frontal location in 5 patients (41.7%), temporal in 3 patients (25%), in the basal ganglia in 2 (16.7%), in the parietal lobe in 1 (8.3%), and the occipital lobe in 1 patient. Most of the lesions were small; <5mm in 7 patients, 5–10mm in 3 patients, and >10mm in 2 patients (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Only 1 of the 3 patients with TIA after CAS had lesions.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Morphologic analysis of filtersHistologic analysis of the filter content revealed the presence of material in 49 of them (64.5%). In more than 75% of cases, particles were <1λ, but no filter showed particles >10λ (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Analysis of the retrieved material revealed the presence of fibrin and platelet aggregates, cellular debris and cholesterol crystals, predominantly (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a> and <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Material inside the filters was found in 8 of the 12 patients with de novo ischemic lesions after CAS, mainly small particles (6 patients, 75%), which was not statistically significant in the chi-square tests (p=.977). Similarly, the appearance of lesions on DWI did not correlate with the composition of the material retrieved (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>No statistically significant correlation was found between the presence, volume or characteristics of the filter material or the appearance of ischemic lesions on DWI and any of the clinical, procedural or demographic variables analyzed, including age. In this respect, age showed no significant correlation with the presence of debris in filters or the appearance of new lesions on DWI after CAS (p=.90 and p=.787, respectively) in the ANOVA and Student's t-test.DiscussionThe results of our study can be summarized as follows: (1) the appearance of ischemic lesions after CAS showed no correlation with the embolic load of the filters, its volume or composition, and (2) none of the variables analyzed in our series showed correlation or a tendency to be associated with the volume of debris or the appearance of ischemic lesions.DWI has become the technique of choice for the evaluation of potential ischemic brain damage during recanalization of ICA (in line with most other studies on the matter).In our series, the percentage of ischemic lesions after CAS was lower than in other studies with similar design.<a class="elsevierStyleCrossRefs" href="#bib0035">7,16,17</a> We found 2 patients with lesions in the posterior fossa and/or in the territory contralateral to the treated ICA, which could be explained by the performance of the angiography of supra-aortic branches and selective of CCAs and vertebral arteries that all patients underwent before CAS.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> The ICSS-MRI—a recent substudy of the randomized ICSS,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> aimed to compare ischemic brain injury after CAS with ischemic injury after EC—concludes that patients in the CAS group had up to three times more ischemic lesions than those in the surgery group (50% vs 17%; p<.0001). The study also questions the efficacy of distal filters (73% of patients who underwent CAS with distal protection filters had lesions on post-procedural DWI scans as compared with 17% of patients who underwent EC; p<.0001). Although we assume that the results of case series and randomized trials cannot be compared, the high percentage of ischemic lesions after CAS reported by the ICSS-MRI is striking. Roffi et al.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> criticize the clinical outcome of ICSS implying that the experience required to perform CAS to be eligible for the studies was minimal. This would explain why patients who underwent CAS had a higher risk of 30-day stroke or death compared with patients who underwent CE. Maybe, we will soon find references along the same lines in the literature trying to justify the ICSS-MRI results. After all, the technique and experience of the team performing CAS is the main factor associated with immediate procedural success, both clinical and by neuroimaging.Despite everything, there is always a greater or lesser risk of embolization into the cerebral vasculature associated with CAS. Despite the histologically confirmed brain resistance to emboli-mediated ischemia,<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> we are also witnessing the neurocognitive damage that these apparently “silent” lesions may cause.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Plaque vulnerability (composition, inflammation, remodeling) and the severity of stenosis have emerged as the most important determinants for the development of an ischemic episode. Lipid-rich cores surrounded by a thin or disrupted cap of fibrous tissue are associated with the presence of stroke.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> In this respect, neuroimaging tends to refocus its attention from the stenosis towards the morphology and structure of the plaque. Several authors have already established a relationship between plaque structure and the presence of cerebral stroke, mainly correlating the ultrasonic echolucency of the artery wall with the appearance of cerebral lesions on CT,<a class="elsevierStyleCrossRefs" href="#bib0115">23–25</a> up until the advent of an affordable and highly sensitive technique for the detection of brain lesions and characterization of the carotid arteries, such as MRI. Ouhlous et al.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> reported a clear correlation between the presence of a lipid-rich core on MRI and the presence of more frequent and numerous ipsilateral cerebral strokes, most often involving the centrum semiovale, in symptomatic patients with severe carotid artery stenosis. The attempt to establish the correlation between clinical and procedural variables and mechanism of cerebral embolism, through quantification and histologic characterization of the particles trapped in the distal protection devices used in revascularization procedures performed in various locations, is recent.<a class="elsevierStyleCrossRefs" href="#bib0135">27–30</a> In addition to our study, only one study correlates the presence of silent lesions on DWI in both symptomatic and asymptomatic patients with the direct analysis of plaque components after retrieval of embolic material. Maleux et al.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> report a similar result, with no correlation between filter content and the appearance of cerebral ischemia after CAS (p=.087), although they report a significantly higher number of lesions detected by DWI and their particle analysis is based only on optical microscope findings. In both series, the a posteriori analysis allows evaluation of the composition of the material but not of the architecture of the artery wall, as this material is the result of mechanical damage of the intimal surface secondary to manipulation during CAS.In our series, the morphologic analysis revealed that 64.5% of filters contained material, the vessel wall and the atherosclerotic plaque being the main source of particles, predominantly fibrin and platelet aggregates, cellular debris and cholesterol crystals. In line with other authors,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> our group found no significant correlation between clinical, angiographic or procedural variables and the histologic classification of the retained particles, which suggests that the main determinants of the composition of the embolic material are the plaque components themselves. These data support the idea of plaque vulnerability and confirm the importance of its characterization before any interventional procedures, having at our disposal increasingly more sensitive neuroimaging techniques. Most filters used by our group consisted of a PTFE grid with a 100μm pore diameter, which would explain the passage of particles with the smallest volume through the pores to the cerebral vasculature and the potential presence of lesions. Nonetheless, DWI results and the fact that the volume of the particles encountered was <1λ in more than 75% of patients did not support this theory. No particles >10λ were found in our series. In this respect, several theories could be proposed. One of them, supported by Wittkugel et al., explains that the size of the particles retained in the filters is different from the size at the moment of embolization, and that the large quantity of very small emboli would be the result of fragmentation of particles trying to pass through the grid of the filter mesh.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Furthermore, it is also possible that if we consider that the released emboli are primarily of small volume, they are able to cause brain damage not detected by neuroimaging and we have therefore overestimated the detection capability of DWI, or we have underestimated the brain resistance to ischemic damage. Similarly, filter placement and retrieval involves unavoidable embolization of microparticles, and manipulation during the procedure would explain the presence of some periprocedural lesions. The predominance of fibrin-platelet aggregates in the histologic analysis has also been confirmed by other authors. Sprouse et al.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> point out that the high amount of this component in the outer surface of the filters could be the cause of pore occlusion. In our series, this might not be considered the only and main cause of obstruction, if we take into consideration that these aggregates were found in 27.6% of the filters but there were only 3 cases of device occlusion.Authors such as Sprouse or Mudra reported an association between filter debris and specific clinical variables, such as hypertension and hypercholesterolemia.<a class="elsevierStyleCrossRefs" href="#bib0165">33,34</a> In our series, none of the variables showed correlation with the presence of material captured by the filters or with the presence of focal infarcts after CAS. In our opinion, the lack of negative influence of the variables that carry some weight, such as age, together with the lower prevalence of lesions encountered seems to be largely determined by the rigorous selection of candidates for CAS. In addition, the procedure was performed by a multidisciplinary team whose members have a long standing experience working together and where the clinical and angiographic characteristic of each and every patient were taken into consideration.<a class="elsevierStyleCrossRefs" href="#bib0175">35–37</a>Some limitations of the study should be noted. First, measurement of the volume and not the dimensions of particles limit the comparison between series and hinders the comparison between particle size and pore diameter. Second, the lack of a morphologic study of the plaque-arterial wall complex (in the absence of an in-block excision) makes it impossible to include risk variables based on its structure and morphology. To this end, new neuroimaging modalities that our team has already got underway, such as intravascular (endocarotid) ultrasound (IVUS), would be useful. Third, the use of a single b value=1000, applied in each of the three main gradient directions, and the use of 6mm section thickness in this sequence can result in a decrease in sensitivity of ischemic lesion detection, particularly lesions with smaller diameter, which are the most abundant lesions in our series.<a class="elsevierStyleCrossRefs" href="#bib0190">38–40</a> Finally, the series of consecutive patients included in the study were treated at a single center, and therefore we consider a possible selection bias inherent to the study design as the cause of the number of post-procedural ischemic lesions encountered. The fact that sample size was not estimated in advance—recommended for studies involving a large number of variables—may have influenced the number of negative results, in other words, the absence of differences does not allow us to state that there are in fact any differences, nor can we assume that no differences exist.In conclusion, we can say that although distal embolization is a process inherent to CAS that can be reduced with the use of protection filters, the load and composition of emboli are not the sole determinants of focal ischemic lesions, usually silent, that appear in a number of patients undergoing CAS. There are probably clinical and demographic factors associated with increased risk of stroke whose influence could be minimized thanks to the experience of interventional neuroradiologists and a rigorous and personalized selection of patients. In our opinion, homogenization of inclusion and exclusion criteria is necessary as well as the comparison of results with those obtained by groups whose members have undergone similar learning curves, in order to draw reliable conclusions for the assessment of the actual risk groups and the progression of our patients.Authorship<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Conception, design and integrity of the study: PP, AG.</li><li class="elsevierStyleListItem" id="lsti0010">2.Bibliographic search: PP, AG.</li><li class="elsevierStyleListItem" id="lsti0015">3.Acquisition and interpretation of data: PP, AF, FM, AM, JRGM, AGP.</li><li class="elsevierStyleListItem" id="lsti0020">4.Drafting of the paper: PP.</li><li class="elsevierStyleListItem" id="lsti0025">5.Review of the article: AG, FM, JRGM, AGP, AM, AC.</li><li class="elsevierStyleListItem" id="lsti0030">6.Relevant contributions to the final version: AG, AC.</li><li class="elsevierStyleListItem" id="lsti0035">7.Statistical analysis: AC.</li><li class="elsevierStyleListItem" id="lsti0040">8.Approval of the final version: AG, FM, JRGM, AGP, AM, AC.</li></ul>Conflict of interestThe authors declare not having any conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres121908" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objectives" 2 => "Material and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec109193" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres121909" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivos" 2 => "Material y método" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec109194" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design of the study and study population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Neurointerventional procedure" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Histopathologic examination of the filters" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Magnetic resonante technique" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Imaging analysis" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Morphologic analysis of filters" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Authorship" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack37793" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-10-27" "fechaAceptado" => "2010-12-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec109193" "palabras" => array:7 [ 0 => "Carotid stenosis" 1 => "Transluminal angioplasty" 2 => "Stent" 3 => "Cerebral ischemia" 4 => "Arteriosclerosis" 5 => "Histology" 6 => "Diffusion-weighted imaging" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec109194" "palabras" => array:7 [ 0 => "Estenosis carotídea" 1 => "Angioplastia transluminal" 2 => "Stent" 3 => "Isquemia cerebral" 4 => "Arteriosclerosis" 5 => "Histología" 6 => "Imagen potenciada en difusión" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectivesTo evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting (CAS) and the development of ischemic brain lesions in diffusion-weighted imaging (DWI).To determine the influence of demographic, clinical, and procedural variables in the pathogenesis of emboli and in ischemia after CAS. Material and methodsWe submitted the contents of the filters of 76 patients (60 men; mean age, 68.39 years; range, 46–82) who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery (ICA) for histologic analysis evaluating volume (<1λ=0.001ml=1μl; 1–10λ; and >10λ) and the composition of the particles. All patients underwent DWI before and 24h after the procedure; we recorded whether lesions appeared, their number, size, and distribution. We correlated the findings with demographic, clinical, and procedural variables. ResultsSymptoms were present before the procedure in 58 (76.3%) patients. Particles were present in 49 (64.5%) of the filters; most particles (77.5%) were 1λ with a predominance of fibrin-platelet aggregates, cell remnants, and cholesterol crystals. DWI after the procedure detected lesions in 12 (15.8%) patients. We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables. ConclusionsIschemia after CAS does not depend solely on the embolic load and its nature. We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivosEvaluar la relación entre el material recogido en filtros distales tras angioplastia y colocación de stent carotídeo (ASC) y la aparición de lesiones isquémicas cerebrales en la RM potenciada en difusión (RMD).Determinar la influencia que tienen variables demográficas, clínicas y del procedimiento en el proceso embolígeno y en la isquemia post-ASC. Material y métodoSe analizó histológicamente el contenido de los filtros de 76 pacientes sometidos a ASC por estenosis grave de la arteria carótida interna (ACI) (60 hombres; edad media 68,39 años; rango: 46–82), valorándose el volumen (<1λ=0,001ml=1μl; 1–10λ; y >10λ) y la composición de las partículas. Se realizó RMD previa y 24h después del procedimiento, recogiéndose la aparición de lesiones, número, tamaño y distribución. Se correlacionaron estadísticamente los datos anteriores y con variables demográficas, clínicas y del procedimiento. ResultadosCincuenta y ocho pacientes (76,3%) presentaron sintomatología previa al procedimiento. El 64,5% de los filtros (49) presentó partículas, la mayoría menores de 1λ (77,5%), predominando los agregados fibrinoplaquetarios, restos celulares y cristales de colesterol. Doce pacientes (15,8%) demostraron lesiones en la RMD post-ASC, sin relación con el contenido en los filtros. No se encontró correlación estadística entre la presencia de material en los filtros y otras variables. ConclusionesLa isquemia post-ASC no depende únicamente de la carga embolígena y su naturaleza. La menor prevalencia de lesiones post-ASC en nuestra serie en comparación con otras indica que la adecuada selección de pacientes y la experiencia minimizan la influencia negativa de algunas variables, como la edad, en su aparición." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Piñero González de la Peña P, et al. Contenido en filtros tras angioplastia y colocación de stent carotídeo: relación con lesiones isquémicas en la resonancia magnética de difusión. Radiología. 2012;54:155–64." ] ] "multimedia" => array:9 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 635 "Ancho" => 1780 "Tamanyo" => 104683 ] ] "descripcion" => array:1 [ "en" => "Filter with content before (A) and after (B) being cut open for histologic analysis." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 677 "Ancho" => 903 "Tamanyo" => 75267 ] ] "descripcion" => array:1 [ "en" => "Quantitative analysis of the filter content. Drops with 10-, 5-, and 1-λ volumes are shown as reference; 1λ is equivalent to 1μl (0.001ml) or 1mm3." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 750 "Ancho" => 1458 "Tamanyo" => 56495 ] ] "descripcion" => array:1 [ "en" => "Prototype of new ischemic lesions after CAS. Two patients with normal DWI before CAS (not shown). After the procedure, hyperintense lesions <1cm are seen in a cortical location in both parietal lobes (A) and in a subcortical location in the right frontal lobe (B)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1287 "Ancho" => 1833 "Tamanyo" => 424494 ] ] "descripcion" => array:1 [ "en" => "Electron microphotograph of the 3 main components found in the filters: platelet aggregates (A), cellular debris (B), and cholesterol crystals (C). (Lead citrate and uranyl acetate, original magnification, 25,000×.)" ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "TIA: transient ischemic attack; AF: amaurosis fugax; CE: coronary disease; PVD: peripheral vascular disease; HLP: hyperlipidemia; AHT: arterial hypertension; MRL: minimal residual lesion." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. (%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No. of patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (78.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (21.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean age/range (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68.39 (46–82) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 (76.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TIA/AF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 (34.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minor stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (23.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stroke with MRL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (18.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (23.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular risk factors</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 (48.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (78.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HLP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 (56.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (47.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (31.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PVS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (25) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab209351.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic data of patients." ] ] 5 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "RICA: right internal carotid artery; LICA: left internal carotid artery; ACoA: anterior communicating artery; PCoA: posterior communicating artery." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. (%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RICA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 (56.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LICA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 (43.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">% stenosis(treated artery)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70–85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (38.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86–99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47 (61.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">% contralateral stenosis</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47 (61.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70–99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (18.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (19.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ulcerated plaque \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (47.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Calcified plaque \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 (50) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Functioning ACoA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (80.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Functioning PCoA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (44.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intracraneal lesion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (5.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dissection post-CAS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (6.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transient symptomatic vasospasm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (28.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Filter occlusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (3.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab209353.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Angiographic characteristics of patients." ] ] 6 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Note: 1λ=0.001ml=1μl=1mm3." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Content \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. (%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Presence of material in the filter</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (35.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 (64.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Volume of the material (49 positive cases)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤1λ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 (77.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>1λ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (22.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>10λ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab209350.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Anatomic study of the filter content after CAS (76 cases)." ] ] 7 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. (%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Platelet-fibrin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (27.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cellular debris \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (26.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cholesterol crystals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (25) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Foam cells \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (11.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Collagen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (5.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Amorphous material \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (3.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Calcium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (3.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smooth muscle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Capillaries \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab209349.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution of the composition of retrieved material." ] ] 8 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">DWI+(n %) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Statistical significance \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Platelet-fibrin</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">p=.553</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cellular debris</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p=.599</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (16.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cholesterol crystals</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (15.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">p=.644</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (16.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Foam cells</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">p=.558</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Collagen</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">p=.490</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (16.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Amorphous material</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">p=.588</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Calcium</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">p=.588</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smooth muscle</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">p=.704</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (16.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Capillaries</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">p=.840</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 (16.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab209352.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Relationship between the appearance of new ischemic lesions after CAS and structure of material retrieved from distal filters (χ2)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack. 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Contenido en filtros tras angioplastia y colocación de stent carotídeo: relación con lesiones isquémicas en la resonancia magnética de difusión

P. Piñero González de la Peñaa,

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pilar.pinero.sspa@juntadeandalucia.es

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, A. González Garcíab, F. Moniche Álvarezc, A. Mayol Deyáb, J.R. González Marcosc, A. Cayuela Domínguezd, A. Gil Peraltac

a Unidad de Neurorradiología Diagnóstica, Servicio de Radiodiagnóstico, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain

b Unidad de Neurorradiología Intervencionista, Unidad de Gestión Clínica de Radiodiagnóstico, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain

c Servicio de Neurología, Unidad de Gestión Clínica de Neurociencias, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain

d Servicio de Documentación Clínica y Estadística, Hospitales Universitarios Virgen del Rocío, Sevilla, Spain

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The content of the filters was submitted for histologic analysis&#44; recording the volume and composition of the material retrieved after performing CAS with placement of distal protection devices for the treatment of patients with high-grade ICA stenosis according to the NASCET criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Between July 2003 and January 2005&#44; 76 patients &#40;60 men &#91;78&#46;9&#37;&#93;&#59; mean age&#44; 68&#46;39 years &#91;range 46&#8211;82&#93;&#41; in whom pre- and post-procedural DWI studies were available were evaluated&#46; Inclusion and exclusion criteria have been described elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Before CAS&#44; neurologic examination and recording of demographic data&#44; and vascular risk factors were performed by three neurologists &#40;FM&#44; JRGM&#44; AGP&#41; with experience in cerebrovascular disease and who classified patients according to the NIHSS&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The study complies with the Declaration of Helsinki and was approved by our institutional review board&#46; Written consent for the procedure and related tests was obtained from all patients&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Neurointerventional procedure</span><p id="par0035" class="elsevierStylePara elsevierViewall">All procedures were performed by two interventional neuroradiologists &#40;AG&#44; AM&#41; with extensive experience in endovascular treatment of carotid disease&#46; Briefly&#44; the procedure involved the placement&#8212;using the femoral approach and after local anesthesia&#8212;of a 6F long sheath catheter &#40;90<span class="elsevierStyleHsp" style=""></span>cm&#41; in the common carotid artery &#40;CCA&#41;&#46; The filters were deployed crossing the stenosis through the catheter&#46; Four types of filters were used&#58; EPI and EZ FilterWires &#40;Boston Scientific&#47;Target Therapeutics&#44; Fremont&#44; CA&#41;&#44; Spider &#40;ev3&#44; Plymouth&#44; MN&#41;&#44; and Accunet &#40;Guidant&#44; Santa Clara&#44; CA&#41;&#44; with an 80&#8211;130<span class="elsevierStyleHsp" style=""></span>&#956;m pore size&#46; Once the filter was placed and expanded&#44; a predilation of the stenosis with a low-profile balloon &#40;2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm&#41; was performed in all patients&#44; and a self-expandable stent was placed in the stenotic segment &#40;Carotid Wallstent &#91;CWS&#93;&#44; Boston Scientific&#47;Target Therapeutics&#44; or carotid Acculink&#44; Guidant&#41;&#46; When needed&#44; postdilation was performed with a 5&#8211;6<span class="elsevierStyleHsp" style=""></span>mm balloon catheter&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients were on antiplatelet therapy &#40;125<span class="elsevierStyleHsp" style=""></span>mg&#47;day aspirin and 75<span class="elsevierStyleHsp" style=""></span>mg&#47;day clopidogrel&#41; at least for 3 days and on anticoagulant therapy &#40;unfractionated IV heparin&#41; for 48<span class="elsevierStyleHsp" style=""></span>h before CAS&#46; Hemodynamic and electroencephalographic &#40;EEG&#41; changes were monitored during the procedures&#44; and episodes of hypotension&#44; bradycardia&#44; asystole&#44; and syncope were recorded&#46; Before arterial catheterization&#44; a dose of heparin required to maintain the activated clotting time &#40;ACT&#41; between 250 and 300<span class="elsevierStyleHsp" style=""></span>s was administered&#46; Patients were discharged on clopidogrel &#40;75<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; for a month and aspirin &#40;125<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; or triflusal &#40;600<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; permanently&#46; Clinical examination was performed in all patients with a Doppler ultrasound of supra-aortic branches after 1&#44; 3&#44; 6 and 12 months after CAS&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The 30-day morbidity and mortality were registered &#40;transient ischemic attack &#91;TIA&#93;&#44; minor and major stroke&#44; acute myocardial infarction &#91;AMI&#93; and death&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Histopathologic examination of the filters</span><p id="par0050" class="elsevierStylePara elsevierViewall">An experienced neuropathologist &#40;ER&#41; examined all filters after retrieval&#46; The filters were removed from the guidewire&#44; cut open along the long axis&#44; and examined under optical microscope&#46; The particles were removed from the filter by using microforceps&#44; fixed in paraformaldehyde&#44; embedded in EPON &#40;Resolution Performance Products&#44; Houston&#44; TX&#41;&#44; cut into thin sections&#44; stained with lead citrate&#44; and examined under an electron microscope&#46; Photographs of the filters after removal from the guidewire were taken before and after being cut open &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">A semiquantitative analysis of the embolic material removed from the filters was performed&#46; A sample was considered to have a maximal load when the volume was &#62;10 lambdas &#40;1<span class="elsevierStyleHsp" style=""></span>&#955;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span>&#41;&#44; moderate when the volume was &#62;1<span class="elsevierStyleHsp" style=""></span>&#955;&#44; and minimal when it was &#60;1<span class="elsevierStyleHsp" style=""></span>&#955; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Magnetic resonante technique</span><p id="par0060" class="elsevierStylePara elsevierViewall">All patients underwent a complete MR examination in the three days before CAS and DWI 24<span class="elsevierStyleHsp" style=""></span>h after the procedure on a 1&#46;5 T MRI system &#40;Intera&#44; Philips Medical Systems&#44; Best&#44; The Netherlands&#41; with a brain coil&#46; Pre-CAS protocol included axial and sagittal T1-weighted spin echo sequences &#40;TR&#47;TE&#44; 539&#47;13&#59; 2 excitations&#41;&#44; axial T2&#47;proton density &#40;3402&#47;8&#8211;110&#41;&#44; field echo-echo planar &#40;1460&#47;23&#59; flip angle&#44; 20&#176;&#41;&#44; coronal FLAIR &#40;8000&#47;120&#59; TI&#44; 2200&#41; sequences&#44; and 3D MR angiography of supra-aortic branches after administration of contrast agent &#40;slab thickness 60<span class="elsevierStyleHsp" style=""></span>mm&#44; 60 sections&#41;&#46; A bolus of gadopentetate dimeglumine &#40;Magnevist<span class="elsevierStyleSup">&#174;</span>&#41; was injected at a flow rate of 2&#46;5<span class="elsevierStyleHsp" style=""></span>ml&#47;s&#44; followed by a 30<span class="elsevierStyleHsp" style=""></span>ml saline flush using an MR compatible injector system &#40;Spectris&#59; Medrad&#44; Pittsburgh&#44; PA&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">DWI was obtained with a spin-echo echo-planar sequence &#40;3562&#47;95&#59; echo-planar imaging factor&#44; 77&#59; section thickness&#44; 6&#46;0<span class="elsevierStyleHsp" style=""></span>mm&#59; intersection gap&#44; 1<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; with <span class="elsevierStyleItalic">b</span> values of 0 and 1000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#44; with the latter value applied in each of the three main gradient directions &#40;<span class="elsevierStyleItalic">x</span>&#44; <span class="elsevierStyleItalic">y</span>&#44; <span class="elsevierStyleItalic">z</span>&#41;&#46; Apparent diffusion coefficient &#40;ADC&#41; maps were obtained in all patients&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Imaging analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">A neuroradiologist &#40;PP&#41; blinded to patient and procedural characteristics evaluated the MR images&#46; In the pre-CAS MR examinations&#44; the presence of atrophy&#44; leukoaraiosis&#44; lacunar lesions&#44; and brain infarct&#44; as described elsewhere in the literature&#44; were recorded&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> On the DWI sequence&#44; the presence of acute ischemic lesions &#40;defined as lesions with conspicuous hyperintensity on the diffusion sequence with a <span class="elsevierStyleItalic">b</span> value<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1000&#44; and hypointensity on the ADC map&#41; was evaluated&#46; These findings were compared with presence of new ischemic lesions&#44; their number and size &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>mm&#44; 5&#8211;10<span class="elsevierStyleHsp" style=""></span>mm&#44; &#62;10<span class="elsevierStyleHsp" style=""></span>mm in the transverse axis&#41;&#44; distribution &#40;cortical&#44; subcortical&#44; deep&#41;&#44; and anatomic and vascular location on post-procedural DWI&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Data were analyzed by an expert &#40;AC&#41; with the software package SPSS &#40;SPSS 15&#46;0&#44; Chicago&#44; IL&#41;&#46; Qualitative variables were expressed as relative and absolute frequencies&#44; and quantitative variables&#44; as the median and standard deviation&#46; A bivariate analysis was performed with the chi-square test to correlate the volume and characteristics of the particles retrieved from the filter with the presence of new ischemic lesions on postprocedural DWI&#46; The chi-square test &#40;for qualitative variables&#41; and the Student&#39;s <span class="elsevierStyleItalic">t</span>-test or the ANOVA test &#40;for quantitative dependent variables and dichotomies or &#62;2 categories of independent variables&#44; respectively&#41; were used to correlate a number of demographic variables&#44; vascular risk factors&#44; periprocedural hemodynamic complications or morbidity and mortality after CAS with the presence of new ischemic lesions on DWI and with the volume and characteristics of the particles&#46; A <span class="elsevierStyleItalic">p</span> value &#60;&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">A total of 76 ICA were treated in 76 patients&#46; Demographic and angiographic characteristics are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46; Vascular risk factors were common&#44; especially hypertension &#40;78&#46;9&#37;&#41; and hypelipidemia &#40;56&#46;6&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Symptomatic patients &#40;76&#46;3&#37;&#41; underwent the procedure at least four weeks after the schemic attack&#44; but in 5 patients &#40;6&#46;6&#37;&#41; it was performed on an emergency basis&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A distal filter was used in all patients&#59; the distribution by type of filter was as follows&#58; EZ in 39 patients &#40;51&#46;3&#37;&#41;&#44; EPI in 14 &#40;18&#46;4&#37;&#41;&#44; Spider in 14 &#40;18&#46;4&#37;&#41;&#44; and Accunet in 9 &#40;11&#46; 8&#37;&#41;&#46; In 56 patients &#40;73&#46;7&#37;&#41;&#44; &#8804;2 dilations were required before stent placement&#46; In the remaining 20 patients &#40;26&#46;3&#37;&#41;&#44; &#8805;3 dilations were needed&#46; During the procedure vasospasm occurred in 22 cases and dissection of the intima occurred in 5 cases&#44; without relevant clinical consequences&#46; A total of 76 stents were placed &#40;in one patient&#44; 2 stents were used and other patient underwent angioplasty without stent placement&#41;&#58; CWS were placed in 43 &#40;56&#46;6&#37;&#41;&#44; and Acculink in 33 &#40;43&#46;4&#37;&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Transient hemodynamic complications were as follows&#58; syncope in 19 patients &#40;25&#37;&#41;&#44; bradycardia in 40 &#40;52&#46;6&#37;&#41;&#44; hypotension in 33 &#40;43&#46;4&#37;&#41; and asystole in 21 &#40;27&#46;6&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">After CAS&#44; 3 patients &#40;3&#46;9&#37;&#41; developed TIA&#44; lasting less than 15<span class="elsevierStyleHsp" style=""></span>min&#46; No major&#44; minor stroke or AMI occurred in the 30-day period following the procedure&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Before CAS&#44; DWI showed acute focal ischemic lesions in 9 patients &#40;11&#46;8&#37;&#41;&#46; Twenty-nine lesions were detected&#46; In 5 patients&#44; the lesions were multiple &#40;4 patients with 4 lesions and 1 with 8&#41;&#46; After CAS&#44; DWI showed 27 lesions in 12 patients &#40;15&#46;8&#37;&#41;&#46; There were 6 patients with a single lesion&#59; 1 patient with 2 lesions&#59; 3 patients with 3 lesions&#59; 1 with 4 lesions&#44; and other patient with 6 lesions&#46; In 10 of them &#40;83&#46;3&#37; of the patients with lesions after CAS&#41;&#44; the lesions were located in the territory ipsilateral to the treated artery&#46; There was 1 patient &#40;1&#46;3&#37;&#41; with lesions in the posterior fossa and other patient with lesions in posterior fossa and in the territory contralateral to the treated ICA&#46; The lesions were in a cortical location in 5 patients &#40;41&#46;7&#37;&#41;&#44; cortical&#8211;subcortical in 3 patients&#44; in deep white matter in 2&#44; subcortical in 1 patient&#44; and in 1 patient in a border zone&#46; As for brain location&#44; lesions were in a frontal location in 5 patients &#40;41&#46;7&#37;&#41;&#44; temporal in 3 patients &#40;25&#37;&#41;&#44; in the basal ganglia in 2 &#40;16&#46;7&#37;&#41;&#44; in the parietal lobe in 1 &#40;8&#46;3&#37;&#41;&#44; and the occipital lobe in 1 patient&#46; Most of the lesions were small&#59; &#60;5<span class="elsevierStyleHsp" style=""></span>mm in 7 patients&#44; 5&#8211;10<span class="elsevierStyleHsp" style=""></span>mm in 3 patients&#44; and &#62;10<span class="elsevierStyleHsp" style=""></span>mm in 2 patients &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Only 1 of the 3 patients with TIA after CAS had lesions&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Morphologic analysis of filters</span><p id="par0110" class="elsevierStylePara elsevierViewall">Histologic analysis of the filter content revealed the presence of material in 49 of them &#40;64&#46;5&#37;&#41;&#46; In more than 75&#37; of cases&#44; particles were &#60;1<span class="elsevierStyleHsp" style=""></span>&#955;&#44; but no filter showed particles &#62;10<span class="elsevierStyleHsp" style=""></span>&#955; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Analysis of the retrieved material revealed the presence of fibrin and platelet aggregates&#44; cellular debris and cholesterol crystals&#44; predominantly &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> and <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Material inside the filters was found in 8 of the 12 patients with de novo ischemic lesions after CAS&#44; mainly small particles &#40;6 patients&#44; 75&#37;&#41;&#44; which was not statistically significant in the chi-square tests &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;977&#41;&#46; Similarly&#44; the appearance of lesions on DWI did not correlate with the composition of the material retrieved &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">No statistically significant correlation was found between the presence&#44; volume or characteristics of the filter material or the appearance of ischemic lesions on DWI and any of the clinical&#44; procedural or demographic variables analyzed&#44; including age&#46; In this respect&#44; age showed no significant correlation with the presence of debris in filters or the appearance of new lesions on DWI after CAS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;90 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;787&#44; respectively&#41; in the ANOVA and Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The results of our study can be summarized as follows&#58; &#40;1&#41; the appearance of ischemic lesions after CAS showed no correlation with the embolic load of the filters&#44; its volume or composition&#44; and &#40;2&#41; none of the variables analyzed in our series showed correlation or a tendency to be associated with the volume of debris or the appearance of ischemic lesions&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">DWI has become the technique of choice for the evaluation of potential ischemic brain damage during recanalization of ICA &#40;in line with most other studies on the matter&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In our series&#44; the percentage of ischemic lesions after CAS was lower than in other studies with similar design&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;16&#44;17</span></a> We found 2 patients with lesions in the posterior fossa and&#47;or in the territory contralateral to the treated ICA&#44; which could be explained by the performance of the angiography of supra-aortic branches and selective of CCAs and vertebral arteries that all patients underwent before CAS&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The ICSS-MRI&#8212;a recent substudy of the randomized ICSS&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> aimed to compare ischemic brain injury after CAS with ischemic injury after EC&#8212;concludes that patients in the CAS group had up to three times more ischemic lesions than those in the surgery group &#40;50&#37; vs 17&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; The study also questions the efficacy of distal filters &#40;73&#37; of patients who underwent CAS with distal protection filters had lesions on post-procedural DWI scans as compared with 17&#37; of patients who underwent EC&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; Although we assume that the results of case series and randomized trials cannot be compared&#44; the high percentage of ischemic lesions after CAS reported by the ICSS-MRI is striking&#46; Roffi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> criticize the clinical outcome of ICSS implying that the experience required to perform CAS to be eligible for the studies was minimal&#46; This would explain why patients who underwent CAS had a higher risk of 30-day stroke or death compared with patients who underwent CE&#46; Maybe&#44; we will soon find references along the same lines in the literature trying to justify the ICSS-MRI results&#46; After all&#44; the technique and experience of the team performing CAS is the main factor associated with immediate procedural success&#44; both clinical and by neuroimaging&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Despite everything&#44; there is always a greater or lesser risk of embolization into the cerebral vasculature associated with CAS&#46; Despite the histologically confirmed brain resistance to emboli-mediated ischemia&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> we are also witnessing the neurocognitive damage that these apparently &#8220;silent&#8221; lesions may cause&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Plaque vulnerability &#40;composition&#44; inflammation&#44; remodeling&#41; and the severity of stenosis have emerged as the most important determinants for the development of an ischemic episode&#46; Lipid-rich cores surrounded by a thin or disrupted cap of fibrous tissue are associated with the presence of stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> In this respect&#44; neuroimaging tends to refocus its attention from the stenosis towards the morphology and structure of the plaque&#46; Several authors have already established a relationship between plaque structure and the presence of cerebral stroke&#44; mainly correlating the ultrasonic echolucency of the artery wall with the appearance of cerebral lesions on CT&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;25</span></a> up until the advent of an affordable and highly sensitive technique for the detection of brain lesions and characterization of the carotid arteries&#44; such as MRI&#46; Ouhlous et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> reported a clear correlation between the presence of a lipid-rich core on MRI and the presence of more frequent and numerous ipsilateral cerebral strokes&#44; most often involving the centrum semiovale&#44; in symptomatic patients with severe carotid artery stenosis&#46; The attempt to establish the correlation between clinical and procedural variables and mechanism of cerebral embolism&#44; through quantification and histologic characterization of the particles trapped in the distal protection devices used in revascularization procedures performed in various locations&#44; is recent&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;30</span></a> In addition to our study&#44; only one study correlates the presence of silent lesions on DWI in both symptomatic and asymptomatic patients with the direct analysis of plaque components after retrieval of embolic material&#46; Maleux et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> report a similar result&#44; with no correlation between filter content and the appearance of cerebral ischemia after CAS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;087&#41;&#44; although they report a significantly higher number of lesions detected by DWI and their particle analysis is based only on optical microscope findings&#46; In both series&#44; the a posteriori analysis allows evaluation of the composition of the material but not of the architecture of the artery wall&#44; as this material is the result of mechanical damage of the intimal surface secondary to manipulation during CAS&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In our series&#44; the morphologic analysis revealed that 64&#46;5&#37; of filters contained material&#44; the vessel wall and the atherosclerotic plaque being the main source of particles&#44; predominantly fibrin and platelet aggregates&#44; cellular debris and cholesterol crystals&#46; In line with other authors&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> our group found no significant correlation between clinical&#44; angiographic or procedural variables and the histologic classification of the retained particles&#44; which suggests that the main determinants of the composition of the embolic material are the plaque components themselves&#46; These data support the idea of plaque vulnerability and confirm the importance of its characterization before any interventional procedures&#44; having at our disposal increasingly more sensitive neuroimaging techniques&#46; Most filters used by our group consisted of a PTFE grid with a 100<span class="elsevierStyleHsp" style=""></span>&#956;m pore diameter&#44; which would explain the passage of particles with the smallest volume through the pores to the cerebral vasculature and the potential presence of lesions&#46; Nonetheless&#44; DWI results and the fact that the volume of the particles encountered was &#60;1<span class="elsevierStyleHsp" style=""></span>&#955; in more than 75&#37; of patients did not support this theory&#46; No particles &#62;10<span class="elsevierStyleHsp" style=""></span>&#955; were found in our series&#46; In this respect&#44; several theories could be proposed&#46; One of them&#44; supported by Wittkugel et al&#46;&#44; explains that the size of the particles retained in the filters is different from the size at the moment of embolization&#44; and that the large quantity of very small emboli would be the result of fragmentation of particles trying to pass through the grid of the filter mesh&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Furthermore&#44; it is also possible that if we consider that the released emboli are primarily of small volume&#44; they are able to cause brain damage not detected by neuroimaging and we have therefore overestimated the detection capability of DWI&#44; or we have underestimated the brain resistance to ischemic damage&#46; Similarly&#44; filter placement and retrieval involves unavoidable embolization of microparticles&#44; and manipulation during the procedure would explain the presence of some periprocedural lesions&#46; The predominance of fibrin-platelet aggregates in the histologic analysis has also been confirmed by other authors&#46; Sprouse et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> point out that the high amount of this component in the outer surface of the filters could be the cause of pore occlusion&#46; In our series&#44; this might not be considered the only and main cause of obstruction&#44; if we take into consideration that these aggregates were found in 27&#46;6&#37; of the filters but there were only 3 cases of device occlusion&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Authors such as Sprouse or Mudra reported an association between filter debris and specific clinical variables&#44; such as hypertension and hypercholesterolemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a> In our series&#44; none of the variables showed correlation with the presence of material captured by the filters or with the presence of focal infarcts after CAS&#46; In our opinion&#44; the lack of negative influence of the variables that carry some weight&#44; such as age&#44; together with the lower prevalence of lesions encountered seems to be largely determined by the rigorous selection of candidates for CAS&#46; In addition&#44; the procedure was performed by a multidisciplinary team whose members have a long standing experience working together and where the clinical and angiographic characteristic of each and every patient were taken into consideration&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#8211;37</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Some limitations of the study should be noted&#46; First&#44; measurement of the volume and not the dimensions of particles limit the comparison between series and hinders the comparison between particle size and pore diameter&#46; Second&#44; the lack of a morphologic study of the plaque-arterial wall complex &#40;in the absence of an in-block excision&#41; makes it impossible to include risk variables based on its structure and morphology&#46; To this end&#44; new neuroimaging modalities that our team has already got underway&#44; such as intravascular &#40;endocarotid&#41; ultrasound &#40;IVUS&#41;&#44; would be useful&#46; Third&#44; the use of a single <span class="elsevierStyleItalic">b</span> value<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1000&#44; applied in each of the three main gradient directions&#44; and the use of 6<span class="elsevierStyleHsp" style=""></span>mm section thickness in this sequence can result in a decrease in sensitivity of ischemic lesion detection&#44; particularly lesions with smaller diameter&#44; which are the most abundant lesions in our series&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#8211;40</span></a> Finally&#44; the series of consecutive patients included in the study were treated at a single center&#44; and therefore we consider a possible selection bias inherent to the study design as the cause of the number of post-procedural ischemic lesions encountered&#46; The fact that sample size was not estimated in advance&#8212;recommended for studies involving a large number of variables&#8212;may have influenced the number of negative results&#44; in other words&#44; the absence of differences does not allow us to state that there are in fact any differences&#44; nor can we assume that no differences exist&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In conclusion&#44; we can say that although distal embolization is a process inherent to CAS that can be reduced with the use of protection filters&#44; the load and composition of emboli are not the sole determinants of focal ischemic lesions&#44; usually silent&#44; that appear in a number of patients undergoing CAS&#46; There are probably clinical and demographic factors associated with increased risk of stroke whose influence could be minimized thanks to the experience of interventional neuroradiologists and a rigorous and personalized selection of patients&#46; In our opinion&#44; homogenization of inclusion and exclusion criteria is necessary as well as the comparison of results with those obtained by groups whose members have undergone similar learning curves&#44; in order to draw reliable conclusions for the assessment of the actual risk groups and the progression of our patients&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Authorship</span><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Conception&#44; design and integrity of the study&#58; PP&#44; AG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Bibliographic search&#58; PP&#44; AG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Acquisition and interpretation of data&#58; PP&#44; AF&#44; FM&#44; AM&#44; JRGM&#44; AGP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Drafting of the paper&#58; PP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Review of the article&#58; AG&#44; FM&#44; JRGM&#44; AGP&#44; AM&#44; AC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Relevant contributions to the final version&#58; AG&#44; AC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; AC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Approval of the final version&#58; AG&#44; FM&#44; JRGM&#44; AGP&#44; AM&#44; AC&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare not having any conflict of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Material and methods"
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              "titulo" => "Design of the study and study population"
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              "titulo" => "Neurointerventional procedure"
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              "identificador" => "sec0025"
              "titulo" => "Histopathologic examination of the filters"
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              "identificador" => "sec0030"
              "titulo" => "Magnetic resonante technique"
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              "titulo" => "Imaging analysis"
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              "titulo" => "Morphologic analysis of filters"
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          "identificador" => "xack37793"
          "titulo" => "Acknowledgements"
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          "titulo" => "References"
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    "fechaRecibido" => "2010-10-27"
    "fechaAceptado" => "2010-12-29"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec109193"
          "palabras" => array:7 [
            0 => "Carotid stenosis"
            1 => "Transluminal angioplasty"
            2 => "Stent"
            3 => "Cerebral ischemia"
            4 => "Arteriosclerosis"
            5 => "Histology"
            6 => "Diffusion-weighted imaging"
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          "palabras" => array:7 [
            0 => "Estenosis carot&#237;dea"
            1 => "Angioplastia transluminal"
            2 => "<span class="elsevierStyleItalic">Stent</span>"
            3 => "Isquemia cerebral"
            4 => "Arteriosclerosis"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting &#40;CAS&#41; and the development of ischemic brain lesions in diffusion-weighted imaging &#40;DWI&#41;&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To determine the influence of demographic&#44; clinical&#44; and procedural variables in the pathogenesis of emboli and in ischemia after CAS&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We submitted the contents of the filters of 76 patients &#40;60 men&#59; mean age&#44; 68&#46;39 years&#59; range&#44; 46&#8211;82&#41; who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery &#40;ICA&#41; for histologic analysis evaluating volume &#40;&#60;1<span class="elsevierStyleHsp" style=""></span>&#955;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#956;l&#59; 1&#8211;10<span class="elsevierStyleHsp" style=""></span>&#955;&#59; and &#62;10<span class="elsevierStyleHsp" style=""></span>&#955;&#41; and the composition of the particles&#46; All patients underwent DWI before and 24<span class="elsevierStyleHsp" style=""></span>h after the procedure&#59; we recorded whether lesions appeared&#44; their number&#44; size&#44; and distribution&#46; We correlated the findings with demographic&#44; clinical&#44; and procedural variables&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Symptoms were present before the procedure in 58 &#40;76&#46;3&#37;&#41; patients&#46; Particles were present in 49 &#40;64&#46;5&#37;&#41; of the filters&#59; most particles &#40;77&#46;5&#37;&#41; were 1<span class="elsevierStyleHsp" style=""></span>&#955; with a predominance of fibrin-platelet aggregates&#44; cell remnants&#44; and cholesterol crystals&#46; DWI after the procedure detected lesions in 12 &#40;15&#46;8&#37;&#41; patients&#46; We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ischemia after CAS does not depend solely on the embolic load and its nature&#46; We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Evaluar la relaci&#243;n entre el material recogido en filtros distales tras angioplastia y colocaci&#243;n de <span class="elsevierStyleItalic">stent</span> carot&#237;deo &#40;ASC&#41; y la aparici&#243;n de lesiones isqu&#233;micas cerebrales en la RM potenciada en difusi&#243;n &#40;RMD&#41;&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Determinar la influencia que tienen variables demogr&#225;ficas&#44; cl&#237;nicas y del procedimiento en el proceso embol&#237;geno y en la isquemia post-ASC&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se analiz&#243; histol&#243;gicamente el contenido de los filtros de 76 pacientes sometidos a ASC por estenosis grave de la arteria car&#243;tida interna &#40;ACI&#41; &#40;60 hombres&#59; edad media 68&#44;39 a&#241;os&#59; rango&#58; 46&#8211;82&#41;&#44; valor&#225;ndose el volumen &#40;&#60;1<span class="elsevierStyleHsp" style=""></span>&#955;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#956;l&#59; 1&#8211;10<span class="elsevierStyleHsp" style=""></span>&#955;&#59; y &#62;10<span class="elsevierStyleHsp" style=""></span>&#955;&#41; y la composici&#243;n de las part&#237;culas&#46; Se realiz&#243; RMD previa y 24<span class="elsevierStyleHsp" style=""></span>h despu&#233;s del procedimiento&#44; recogi&#233;ndose la aparici&#243;n de lesiones&#44; n&#250;mero&#44; tama&#241;o y distribuci&#243;n&#46; Se correlacionaron estad&#237;sticamente los datos anteriores y con variables demogr&#225;ficas&#44; cl&#237;nicas y del procedimiento&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Cincuenta y ocho pacientes &#40;76&#44;3&#37;&#41; presentaron sintomatolog&#237;a previa al procedimiento&#46; El 64&#44;5&#37; de los filtros &#40;49&#41; present&#243; part&#237;culas&#44; la mayor&#237;a menores de 1<span class="elsevierStyleHsp" style=""></span>&#955; &#40;77&#44;5&#37;&#41;&#44; predominando los agregados fibrinoplaquetarios&#44; restos celulares y cristales de colesterol&#46; Doce pacientes &#40;15&#44;8&#37;&#41; demostraron lesiones en la RMD post-ASC&#44; sin relaci&#243;n con el contenido en los filtros&#46; No se encontr&#243; correlaci&#243;n estad&#237;stica entre la presencia de material en los filtros y otras variables&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La isquemia post-ASC no depende &#250;nicamente de la carga embol&#237;gena y su naturaleza&#46; La menor prevalencia de lesiones post-ASC en nuestra serie en comparaci&#243;n con otras indica que la adecuada selecci&#243;n de pacientes y la experiencia minimizan la influencia negativa de algunas variables&#44; como la edad&#44; en su aparici&#243;n&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Pi&#241;ero Gonz&#225;lez de la Pe&#241;a P&#44; et al&#46; Contenido en filtros tras angioplastia y colocaci&#243;n de <span class="elsevierStyleItalic">stent</span> carot&#237;deo&#58; relaci&#243;n con lesiones isqu&#233;micas en la resonancia magn&#233;tica de difusi&#243;n&#46; Radiolog&#237;a&#46; 2012&#59;54&#58;155&#8211;64&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Filter with content before &#40;A&#41; and after &#40;B&#41; being cut open for histologic analysis&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Quantitative analysis of the filter content&#46; Drops with 10-&#44; 5-&#44; and 1-&#955; volumes are shown as reference&#59; 1<span class="elsevierStyleHsp" style=""></span>&#955; is equivalent to 1<span class="elsevierStyleHsp" style=""></span>&#956;l &#40;0&#46;001<span class="elsevierStyleHsp" style=""></span>ml&#41; or 1<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span>&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Prototype of new ischemic lesions after CAS&#46; Two patients with normal DWI before CAS &#40;not shown&#41;&#46; After the procedure&#44; hyperintense lesions &#60;1<span class="elsevierStyleHsp" style=""></span>cm are seen in a cortical location in both parietal lobes &#40;A&#41; and in a subcortical location in the right frontal lobe &#40;B&#41;&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Electron microphotograph of the 3 main components found in the filters&#58; platelet aggregates &#40;A&#41;&#44; cellular debris &#40;B&#41;&#44; and cholesterol crystals &#40;C&#41;&#46; &#40;Lead citrate and uranyl acetate&#44; original magnification&#44; 25&#44;000&#215;&#46;&#41;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">TIA&#58; transient ischemic attack&#59; AF&#58; amaurosis fugax&#59; CE&#58; coronary disease&#59; PVD&#58; peripheral vascular disease&#59; HLP&#58; hyperlipidemia&#59; AHT&#58; arterial hypertension&#59; MRL&#58; minimal residual lesion&#46;</p>"
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                  \t\t\t\t">34 &#40;44&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">19 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">9 &#40;11&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Amorphous material&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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        "texto" => "<p id="par0215" class="elsevierStylePara elsevierViewall">We would like to express our gratitude to Dr&#46; Enrique Rafel&#44; from the Anatomic Pathology Department of Hospitales Universitarios Virgen del Roc&#237;o of Seville&#44; for his invaluable assistance in the histologic analysis of the samples and for providing the electron and optical photomicrographs&#46;</p>"
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2012.06.001

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2019 January	0	2	2
2018 December	0	6	6
2018 May	2	1	3
2018 April	13	2	15
2018 March	3	2	5
2018 February	8	3	11
2018 January	2	5	7
2017 December	10	3	13
2017 November	4	2	6
2017 October	13	2	15
2017 September	11	5	16
2017 August	19	17	36
2017 July	14	4	18
2017 June	14	5	19
2017 May	24	0	24
2017 April	11	2	13
2017 March	16	52	68
2017 February	21	2	23
2017 January	17	2	19
2016 December	18	5	23
2016 November	18	9	27
2016 October	14	7	21
2016 September	23	5	28
2016 August	19	4	23
2016 July	24	1	25
2016 June	41	10	51
2016 May	26	9	35
2016 April	20	11	31
2016 March	34	14	48
2016 February	30	18	48
2016 January	28	20	48
2015 December	28	12	40
2015 November	20	8	28
2015 October	19	12	31
2015 September	28	6	34
2015 August	17	7	24
2015 July	17	6	23
2015 June	6	2	8
2015 May	21	9	30
2015 April	31	10	41
2015 March	27	14	41
2015 February	28	3	31
2015 January	21	3	24
2014 December	34	7	41
2014 November	21	1	22
2014 October	28	4	32
2014 September	21	1	22
2014 August	15	4	19
2014 July	27	3	30
2014 June	17	1	18
2014 May	26	6	32
2014 April	22	1	23
2014 March	76	17	93
2014 February	81	12	93
2014 January	75	12	87
2013 December	78	22	100
2013 November	81	15	96
2013 October	97	16	113
2013 September	105	17	122
2013 August	104	18	122
2013 July	64	8	72
2013 June	52	14	66
2013 May	54	10	64
2013 April	59	9	68
2013 March	34	5	39
2013 February	16	6	22
2013 January	13	2	15
2012 December	11	5	16
2012 November	1	1	2

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