Ultrasonic Carotid Thrombolysis

Study Questions:

Does intraoperative sonolysis (ultrasound to facilitate disruption of thrombi) alter the risk of new brain ischemic lesions during carotid endarterectomy (CEA) or carotid stenting (CAS)?

Methods:

The SONOBUSTER trial authors performed a randomized controlled study where patients with internal carotid stenosis ≥70% indicated for CEA/CAS were randomly allocated to sonolysis or controls. Neurological examination, cognitive function tests, and brain magnetic resonance imaging (MRI) were conducted before intervention and at 24 and 30 days post-surgery. A total of 121 patients were allocated to the sonolysis group and 121 to the control group.

Results:

The majority of patients were male and the average age was 66 years. CAS was performed in 56% of the patients; of these, emboli protection was used in all but five patients. New brain ischemic lesions on post-procedure MRI were significantly less frequent in the sonolysis group than in the control group (31.4% of patients vs. 47.1%; p = 0.018). Sonolysis and CEA were identified as independent predictors of reduced brain ischemic lesions (sonolysis: odds ratio [OR], 0.450 [0.215-0.942], p = 0.034 and CEA: OR, 0.208 [0.087-0.495], p < 0.001). Stroke or transient ischemic attack (TIA) occurred in one sonolysis patient and three control patients (p = 0.372). There was no significant difference in post-intervention cognitive test scores (p > 0.3).

Conclusions:

The authors concluded that sonolysis was effective at reducing brain lesions among patients undergoing CAS or CEA.

Perspective:

This interesting proof of concept study suggests that sonolysis could reduce embolic events during carotid revascularization. The clinical impact of this approach is unknown, and larger trials are needed to assess if routine use of this technique is warranted in this patient population.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Vascular Medicine, Interventions and Imaging, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Magnetic Resonance Imaging

Keywords: Brain Infarction, Carotid Stenosis, Diagnostic Imaging, Embolism, Ischemic Attack, Transient, Endarterectomy, Carotid, Magnetic Resonance Imaging, Neurologic Examination, Secondary Prevention, Stents, Stroke, Ultrasonography


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