Remote Ischemic Preconditioning in Carotid Stenting
What is the impact of remote ischemic preconditioning (RIPC) on ischemic injury in patients undergoing carotid artery stenting (CAS)?
The authors randomized patients undergoing carotid stenting to RIPC, sham, and no intervention (control) groups in this pilot study. All subjects received standard medical therapy. Subjects in the RIPC and sham groups underwent RIPC and sham RIPC twice daily, respectively, for 2 weeks prior to CAS. The primary outcomes were the presence of ≥1 newly ischemic brain lesion on DWI within 48 hours after stenting and clinical events within 6 months after stenting.
The study randomized 63 subjects to each arm. Both RIPC and sham RIPC procedures were well tolerated. RIPC was associated with a reduction in number and volume of new DWI lesions. The incidence of new DWI lesions in the RIPC group (15.87%) was significantly lower than the sham group (36.51%; relative risk [RR] 0.44; 96% confidence interval [CI], 0.20-0.91; p < 0.01) and the control group (41.27%; RR, 0.39; 96% CI, 0.21-0.82; p < 0.01). The volume of observed lesions was smaller in the RIPC group compared to the control and sham groups (p < 0.01 each). No severe adverse event was attributed to RIPC and sham RIPC procedures. Clinical ischemic events after CAS were uncommon and did not differ between the three arms (p = 0.597).
The authors concluded that RIPC is safe and appears to reduce ischemic injury in patients undergoing CAS.
RIPC is a promising concept, but has generally failed to deliver the kind of results seen in preclinical studies when tested in adequately powered studies. It is unlikely that the use of RIPC can prevent the occurrence of embolic events, but it could potentially reduce the injury seen after such events. The largest study to date (Hausenloy DJ, et al., N Engl J Med 2015;373:1408-17) that tested RIPC in patients undergoing cardiac surgery was neutral, and the results of this study will need to be validated in a larger adequately designed trial before it can be applied to routine clinical practice.
Keywords: Brain Ischemia, Carotid Artery, Common, Carotid Stenosis, Ischemic Preconditioning, Risk, Stents
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