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The Search for Reliable Markers for Increased Carotid Artery Stenting–Induced Cerebral Embolism

In all randomized controlled trials comparing carotid stenting (CAS) with carotid endarterectomy (CEA) in symptomatic patients, stenting failed to show equal effectiveness in perioperative stroke prevention as compared to CEA. Of note, the main driver of the observed difference in procedural outcome was a significantly higher number of minor strokes in the CAS group of the International Carotid Stenting Study (ICSS), while the number of major strokes and stroke-related death was not significantly different. Analyzing the most probable cause of these procedural minor strokes is warranted in order to make stenting safer and to ultimately facilitate appropriate selection of symptomatic patients who may safely undergo CAS. Furthermore, ICSS subgroup analyses showed a significantly higher number of procedure-induced new cerebral white matter lesions following CAS as compared to CEA. In this issue of the JEVT, Pini et al. studied several clinical and serological markers in relation to periprocedural cerebral embolism in a small cohort of patients undergoing CAS. The authors found female gender and the presence of aortic plaque as clinical markers; representing inflammatory status, high-sensitivity C-reactive protein (hs-CRP) 5 mg/L and serum amyloidA protein (SAA) 10 mg/L were serological predictors of increased cerebral embolism related to CAS. The investigation comprised only 20 consecutive patients, so it should be considered as a pilot study to measure the effect size and serve as the base to initiate a prospective study to analyze the risk markers for periprocedural embolization using a power calculation on the most relevant markers. Several aspects of the pilot study should be clarified and discussed before defining the protocol for such a larger study.