Toshiba; consultant for Abbott, Boston Scientific, Cordis, Covidien, and. CORRESPONDENCE. E640 | VOLUME 79 | NUMBER 5 | NOVEMBER 2016.
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to be successful in the majority of symptomatic, severely stenotic plaques. We also note the trend of other groups,6,7 including the authors,8 away from a “one technique fits all” approach to CAS. We agree with the authors' emphasis on plaque calcification. We have found it helpful to use a carotid plaque morphologybased scale (the “PLAC” scale) based on radiographic factors obtained during preprocedural computed tomographic angiography.9 We found that the degree of plaque calcification (as the authors also assert) and, moreover, the presence or absence of moderate “soft” plaque and the thickness of the calcification itself are the 3 independent risk factors associated with long-term successful outcome. We believe these factors may complement those found useful by the authors during the preprocedural assessment of symptomatic carotid stenosis patients.
8. Dumont TM, Wach MM, Mokin M. Perioperative complications after carotid artery stenting: a contemporary experience from the University at Buffalo neuroendovascular surgery team. Neurosurgery. 2013;73(4):689-694. 9. Pelz DM, Lownie SP, Lee DH, Boulton MR. Plaque morphology (the PLAC Scale) on CT angiography: predicting long-term anatomical success of primary carotid stenting. J Neurosurg. 2015;123(4):856-861.
Disclosure
We thank Lownie et al for their interesting comment on our article entitled “High-Risk Factors in Symptomatic Patients Undergoing Carotid Artery Stenting with Distal Protection: Buffalo Risk Assessment Scale (BRASS).”1 The authors bring forth a number of noteworthy points related to the technique of carotid artery stenting (CAS). Of foremost importance, we would like to stress the point that we do not advocate a “one technique fits all” approach for patients requiring CAS. As the authors correctly noted, we have published a prospective series of our CAS-related complications, in which our patients underwent either proximal or distal protection, rarely requiring balloon angioplasty.2 We estimate our current ratio of proximal-to-distal protection device use to be approximately 1:4. A recent study demonstrated that proximal and distal protection devices have similar associated rates of complications.3 Their use is, therefore, mostly dependent on the anatomy of the lesion. We advocate the use of proximal protection in patients with severe stenosis that hinders the deployment of distal protection devices and in patients with an easily friable, superimposed thrombus that could potentially increase the risk of ischemic stroke secondary to thromboembolism. Our recently published study comprises only our subgroup of symptomatic patients who underwent CAS with the use of distal protection.1 We have yet to determine whether our symptomatic patients who undergo CAS with proximal protection have similar anatomical and medical risk factors for this procedure. We applaud the authors for devising the Predicting Long-Term Outcome with Angioplasty of the Carotid Artery (PLAC) scale for the prediction of long-term outcomes in post-CAS patients on the basis of plaque softness and thickness.4 In that study, the average follow-up duration was 29.7 months, and the study was therefore appropriately labeled as “long-term.” However, it should be noted that the BRASS is a predictor of short-term complications within only 30 days. Whether the factors associated with the PLAC scale are also predictors of short-term complications remains to be studied.
The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
Stephen P. Lownie, MD, FRCSC, FAANS*‡§ David M. Pelz, MD, FRCPC*‡ Manas Sharma, MD*‡ Sachin K. Pandey, MD, FRCPC*‡ Melfort R. Boulton, MD, FRCSC*‡ Donald H. Lee, MBBCh, FRCPC*‡ *Department of Clinical Neurological Sciences London Health Sciences Centre London, Ontario, Canada ‡Department of Medical Imaging London Health Sciences Centre London, Ontario, Canada §Department of Otolaryngology—Head and Neck Surgery London Health Sciences Centre London, Ontario, Canada REFERENCES 1. Fanous AA, Natarajan SK, Jowdy PK, et al. High-risk factors in symptomatic patients undergoing carotid artery stenting with distal protection: Buffalo Risk Assessment Scale (BRASS). Neurosurgery. 2015;77(4):531-543. 2. Lownie SP, Pelz DM, Lee DH, Men S, Gulka I, Kalapos P. Efficacy of treatment of severe carotid bifurcation stenosis by using self-expanding stents without deliberate use of angioplasty balloons. AJNR Am J Neuroradiol. 2005;26(5): 1241-1248. 3. Bussière M, Pelz DM, Kalapos P, et al. Results using a self-expanding stent alone in the treatment of severe symptomatic carotid bifurcation stenosis. J Neurosurg. 2008; 109(3):454-460. 4. Baldi S, Zander T, Rabellino M, Gonzalez G, Maynar M. Carotid artery stenting without angioplasty and cerebral protection: a single center experience with up to 7 years' follow-up. AJNR Am J Neuroradiol. 2011;32(4):759-763. 5. Leonardi M, Dall'olio M, Raffi L, et al. Carotid stenting without angioplasty and without protection: the advantages of a less invasive procedure. Interv Neuroradiol. 2008;14(2):153-163. 6. Ogata A, Sonobe M, Kato N, et al. Carotid artery stenting without post-stenting balloon dilatation. J Neurointervent Surg. 2014;6(7):517-520. 7. Qazi U, Obeid TE, Enwerem N, et al. The effect of ballooning following carotid stent deployment on hemodynamic stability. J Vasc Surg. 2014;59(3): 756-760.
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In Reply: High-Risk Factors in Symptomatic Patients Undergoing Carotid Artery Stenting With Distal Protection: Buffalo Risk Assessment Scale (BRASS)
Disclosures Dr Hopkins has the following interests: grant/research support from Toshiba; consultant for Abbott, Boston Scientific, Cordis, Covidien, and
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Medtronic; financial interests with Boston Scientific, Valor Medical, Claret Medical Inc, Augmenix, Endomation, Silk Road, Ostial, Apama, StimSox, Photolitec, ValenTx, Ellipse, Axtria, NextPlain, and Ocular; board/trustee/ officer position with Claret Medical, Inc; honoraria from Complete Conference Management, Covidien, Memorial Healthcare System. Dr Levy has the following interests: shareholder/ownership interests in Intratech Medical Ltd., Blockade Medical LLC, NeXtGen Biologics; principal investigator for Covidien US SWIFT PRIME Trials; honoraria from Covidien; consultant for Pulsar and Blockade Medical; advisory board member for Stryker, NeXtGen Biologics, and MEDX; other financial support from Abbott for carotid training sessions. Dr Siddiqui has the following interests: financial interests in Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade Medical, Lazarus Effect, Pulsar Vascular, and Medina Medical; consultant for Codman & Shurtleff, Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra, Stryker, Pulsar Vascular, MicroVention, Lazarus Effect, Blockade Medical, Reverse Medical, W.L. Gore & Associates; national steering committees for Penumbra-3D Separator Trial, Covidien-SWIFT PRIME Trial, MicroVentionFRED Trial; speakers' bureau for Codman & Shurtleff, Inc; advisory board for Codman & Shurtleff, Covidien Neurovascular, ICAVL, and Medina Medical; honoraria from Penumbra and Toshiba Medical Systems. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
Andrew A. Fanous, MD*‡ Sabareesh K. Natarajan, MD, MS*‡ Patrick K. Jowdy, MD*‡ Travis M. Dumont, MD*‡§ Maxim Mokin, MD, PhD*‡¶ Jihnhee Yu, PhDk Adam Goldstein*‡ Michael M. Wach, MD*‡ James L. Budny, MD*‡ L. Nelson Hopkins, MD*‡#**‡‡ Kenneth V. Snyder, MD, PhD*‡#**§§ Adnan H. Siddiqui, MD, PhD*‡#**‡‡ Elad I. Levy, MD, MBA*‡#** *Department of Neurosurgery Jacobs School of Medicine and Biomedical Sciences University at Buffalo, State University of New York Buffalo, New York ‡Department of Neurosurgery Gates Vascular Institute Kaleida Health Buffalo, New York
§Division of Neurosurgery, Department of Surgery The University of Arizona Tucson, Arizona ¶Department of Neurosurgery University of South Florida Tampa, Florida kDepartment of Biostatistics University at Buffalo State University of New York Buffalo, New York #Department of Radiology Jacobs School of Medicine and Biomedical Sciences University at Buffalo State University of New York Buffalo, New York **Toshiba Stroke and Vascular Research Center University at Buffalo State University of New York Buffalo, New York ‡‡Jacobs Institute Buffalo, New York §§Department of Neurology Jacobs School of Medicine and Biomedical Sciences University at Buffalo State University of New York Buffalo, New York REFERENCES 1. Fanous AA, Natarajan SK, Jowdy PK, et al. High-risk factors in symptomatic patients undergoing carotid artery stenting with distal protection: buffalo Risk Assessment Scale (BRASS). Neurosurgery. 2015;77(4):531-542; discussion 542-543. 2. Dumont TM, Wach MM, Mokin M, et al. Perioperative complications after carotid artery stenting: a contemporary experience from the university at buffalo neuroendovascular surgery team. Neurosurgery. 2013;73(4):689-693; discussion 693-694. 3. Giri J, Parikh SA, Kennedy KF, et al. Proximal versus distal embolic protection for carotid artery stenting: a national cardiovascular data registry analysis. JACC Cardiovasc Interv. 2015;8(4):609-615. 4. Pelz DM, Lownie SP, Lee DH, Boulton MR. Plaque morphology (the PLAC scale) on CT angiography: predicting long-term anatomical success of primary carotid stenting. J Neurosurg. 2015;123(4):856-861.
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