Original Article | Neurointervention

eISSN 2005-8330
https://doi.org/10.3348/kjr.2019.0030
Korean J Radiol 2019;20(11):1546-1553

Symptomatic Retinal Artery Occlusion after Angioplasty

and Stenting of the Carotid Artery: Incidence and
Related Risk Factors
Sang Joon An, MD1, Young Dae Cho, MD, PhD2, Jeongjun Lee, MD3, Jong Hyeon Mun, MD4,
Dong Hyun Yoo, MD2, Hyun-Seung Kang, MD, PhD5, Yun-jung Yang, PhD6, Moon Hee Han, MD, PhD7
1
Department of Neurology, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea; Departments of
2
Radiology and 5Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea; 3Department of
Neurosurgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea; 4Department of Neurosurgery, Kwangju
Christian Hospital, Gwangju, Korea; 6Institute of Biomedical Science, Catholic Kwandong University International St. Mary’s Hospital, Incheon,
Korea; 7Department of Neurosurgery, Veterans Health Service Medical Center, Seoul, Korea

Objective: Retinal artery occlusion (RAO) is rarely seen as a complication in patients undergoing carotid artery stenting
(CAS); hence, its characteristics have not been documented in detail. This study aimed to investigate the incidence of this
complication and the related risk factors, focusing on differences in ophthalmic artery (OA) supply (whether by the external
or internal carotid artery [ECA or ICA]) prior to CAS procedures.
Materials and Methods: We retrospectively examined 342 patients who underwent CAS for severe and/or symptomatic
carotid artery stenosis between January 2009 and December 2017. Cumulative medical records and radiologic data were
assessed. RAO was confirmed by photography and fluorescent angiography of the fundus, which were performed by an
ophthalmologist. In all patients, distal filter systems of various types were applied as cerebral protection devices (CPDs)
during procedures. Univariate and multivariate analyses were conducted to identify the risk factors for RAO after CAS.
Results: Symptomatic RAO was observed in six patients (1.8%), of which five (6.8%) were ECA-dominant group members (n
= 74). In a binary logistic regression analysis, OA supply by the ECA (odds ratio [OR], 9.705; 95% confidence interval [CI],
1.519–62.017; p = 0.016) and older age (OR, 1.159; 95% CI, 1.005–1.336; p = 0.041) were identified as significant risk
factors in patients with RAO after CAS. ECA-supplied OA was also associated with the severity of ipsilateral ICA stenosis (p
= 0.001) and ulcerative plaque (p = 0.021).
Conclusion: In procedures performed using ICA distal filtering CPD systems, RAO as a complication of CAS (performed for
severe stenosis) showed a relationship to ECA-supplied OA. For older patients, simultaneous use of ICA-ECA CPDs might help
prevent such complications.
Keywords: Carotid artery; Stenosis; Angioplasty; Stent; Retinal artery occlusion

INTRODUCTION does not require access to hostile neck anatomy, among

other advantages. However, CAS is encumbered by a high
Carotid artery stenting (CAS) is an evolving treatment incidence of emboli shed into the distal vascular bed. Such
method for carotid stenosis. In comparison with carotid emboli result from plaque manipulation by guide wires,
endarterectomy (CEA), CAS can be performed without balloon inflation, and stent placement (1, 2).
general anesthesia, involves limited surgical trauma, and Retinal artery occlusion (RAO) is also a potential

Received January 14, 2019; accepted after revision July 15, 2019.
Corresponding author: Young Dae Cho, MD, PhD, Department of Radiology, Seoul National University Hospital, Seoul National University
College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.
• Tel: (822) 2072-2987 • Fax: (822) 743-6385 • E-mail: [email protected]
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://
creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium,
provided the original work is properly cited.

1546 Copyright © 2019 The Korean Society of Radiology

Symptomatic RAO after CAS

complication after CAS, although it is not common. Only a the fundus, performed by an ophthalmologist immediately
few studies have evaluated RAO after CAS procedures, and after onset of visual symptoms.
their findings covered a broad range of incidence (4–15%) The following baseline patient parameters were examined:
(1). The retinal artery is a terminal artery without any age, gender, hypertension, diabetes, hyperlipidemia,
anastomosis among branches and is the only source of prior stroke or transient ischemic attack (TIA), coronary
nutrition for the inner retina. RAO and the corresponding artery disease, atrial fibrillation, chronic renal failure,
loss of blood supply can impair visual acuity and visual and smoking. The following angiographic variables
fields or cause blindness in severe cases (2). This particular were also assessed: symptomatic stenosis, degree of
complication may thus be disabling and can substantially ipsilateral stenosis (based on NASCET criteria), CCA plaque
increase socioeconomic burdens. involvement, ECA stenosis, ulcerative or calcific plaques,
Approximately 28–35% of patients with severe carotid ipsilateral basal perfusion status on a single-photon
artery stenosis (i.e., 70–99% blockage) exhibit reversed emission computed tomography (SPECT) scan of the brain,
flow to ophthalmic arteries (OAs) (3-5). Reversal of OA flow ipsilateral vascular reservoir on a SPECT scan, and OA supply
calls for the development of multiple collaterals and blood source (ECA-dominant vs. ICA-dominant group) prior to CAS.
supply via the external carotid artery (ECA). The OAs are Among procedure-related variables, we analyzed external
then supported by ECA branches, such as the infraorbital pacing, intra-procedural flow compromise, stent type
branch of the superficial temporal artery (STA) or the orbital (closed, open, or mixed-cell), type of cerebral protection
branch of the middle meningeal artery (MMA). During CAS device (CPD), and post-balloon angioplasty. In all patients
procedures in patients with OAs largely supplied by the ECA treated during the study period, various types of distal
(via multiple collaterals), passage of debris toward the ECA filtering systems were used exclusively. Clinical outcomes
can result in the risk of RAO. were assessed in terms of peri-procedural ischemia (TIA,
The association between RAO and OA blood supply in infarction, or RAO) and hemorrhage. This study was
cases involving CAS is not well known. We anticipated approved by our Institutional Review Board.
that the risk of RAO was greater in patients with ECA (vs.
internal carotid artery [ICA]) flow dominance. Thus, the Conventional Angiography and the CAS Procedure
aims of this study were to investigate the incidence of All stenotic lesions were detected using computed
symptomatic RAO after CAS procedures and to identify the tomography angiography, magnetic resonance angiography,
risk factors involved, focusing on the differences between or carotid sonography. All patients underwent cerebral
ECA- and ICA-dominant OA flow. angiography and rotational angiography with three-
dimensional image reconstruction via Innova IGS 630 (GE
MATERIALS AND METHODS Healthcare, Chicago, IL, USA) or another system (Integris
V or AlluraClarity; Philips Medical Systems, Amsterdam,
Study Subjects The Netherlands) to assess the degree and configuration of
In total, 342 consecutive CAS procedures performed at stenosis with precision and to determine the therapeutic
a single institution between January 2009 and December plans.
2017 were examined in this retrospective review. All ECA- or ICA-dominant OA flow was confirmed by ipsilateral
lesions were associated with atherosclerotic ICA and/or carotid angiography prior to CAS by assessing whether the
common carotid artery (CCA) stenosis. Our institutional OA was supplied chiefly and more expeditiously by the ICA
guidelines call for CAS of stenotic ICAs in the following or ECA. Retinochoroidal blushing from ECA collaterals (Fig. 1)
scenarios: severe stenosis (> 75% based on North American or the ICA was also assessed.
Symptomatic Carotid Endarterectomy Trial [NASCET] criteria) Most CAS procedures were performed under local
regardless of symptoms; symptomatic moderate stenosis anesthesia. Patients were pre-treated with aspirin (100 mg/
(> 50 and ≤ 75%); or symptomatic patients with ≤ 50% d) and clopidogrel (75 mg/d) at least 3 days before each
lesion ulceration. CAS procedures performed for arterial procedure. All interventions were carried out via puncture
dissections were excluded from this study. The primary of the femoral artery, followed by administration of heparin
study endpoint was RAO within 3 days after CAS. RAO was (70–100 U/kg) to achieve activated clotting times of 250
confirmed by photography and fluorescent angiography of seconds. Long 6- or 7-Fr carotid sheaths (Flexor Shuttle-SL;

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 An et al.

A B C D

E F G
Fig. 1. Representative case with OA supplied by external carotid artery collaterals.
A-C. Sequential lateral views in common carotid angiography showing OA (black arrowheads) supplied by collateral channel via MMA (white
arrowheads). D. Working projection of severely stenotic proximal internal carotid artery. E. Successful dilatation achieved after carotid
angioplasty and stenting. F. After carotid artery stenting, sluggish OA (black arrowhead) flow supplied by MMA (white arrowhead). G. Fluorescent
angiography of fundus showing multiple occlusions of retinal arteries (arrows). MMA = middle meningeal artery, OA = ophthalmic artery

Cook Medical, Bloomington, IN, USA) were advanced into Various types of self-expandable stents (closed, open,
the CCA and angiograms were recorded. Cerebral protection or mixed-cell) were chosen according to the operator’s
was attempted using various types of distal filtering preference or the stented arterial course. Post-deployment
systems at the operator’s discretion and based on device angiography was routinely performed to evaluate any
availability. Once a filter was placed in the straightest complications or residual stenosis. If significant residual
possible segment, device flow status was routinely tested stenosis (> 30%) persisted without neurologic events
by contrast injection. Thereafter, pre-stent angioplasty was or complications after stent deployment, postdilation
performed using a full-size balloon. Predilation using a 2- to procedures were performed using a larger balloon catheter
3-mm coronary balloon catheter was performed before filter under continuous fluoroscopic monitoring of the filter
placement only if angiography showed that the narrowest position. A retrieval catheter was then introduced over the
vessel diameter was insufficient for passage of the filter filter wire for filter collapse and withdrawal, again using
device. Self-expanding stents were delivered over the 0.014- continuous fluoroscopic monitoring to avoid potential
inch filter guidewire and deployed in relatively straight problems when crossing the stented segment. After the
arterial segments. Stent delivery and catheter retrieval after procedures, completion angiography was performed to
deployment were executed with caution under continuous confirm either distal embolic occlusion or ample perfusion.
fluoroscopic monitoring to maintain the filter’s position. The patients continued the clopidogrel regimen for at least

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Symptomatic RAO after CAS

90 days and the aspirin regimen indefinitely. Comparison of OA Supply Subsets (ECA vs. ICA
Dominance)
Statistical Analysis Prior to CAS, the OA was supplied by the ICA in 268
Continuous variables are expressed as mean ± standard patients (78.4%) and by the ECA in 74 (21.6%). In the
deviation. Chi-squared and Fisher’s exact tests or unpaired latter group (n = 74), the OA was supplied from the orbital
t tests were used to assess categorical or continuous branch of the MMA in 53 patients, the sphenopalatine
variables, respectively. To evaluate the risk factors branch of the internal maxillary artery in 15 patients, the
predisposing patients to symptomatic RAO after CAS, angular branch of the facial artery in four patients, and the
univariate analysis was applied. Multivariate analysis was zygomatico-orbital branch of the STA in two patients. The
then conducted by incorporating variables with p values < characteristics of the patient population are summarized
0.10 in univariate analysis. In multivariate analysis, if the by OA subsets in Table 1. In multivariate analysis, OA
sample size was small, Firth’s method was used. The results was mainly supplied via the ECA collaterals in patients
of a binary logistic regression model were reported as with more advanced stenosis of the ipsilateral ICA (p =
odds ratios (ORs) with 95% confidence intervals (95% CIs) 0.001) and ulcerative plaques (p = 0.021). Although there
and p values. A two-tailed p value < 0.05 was considered were no intergroup differences in terms of postprocedural
statistically significant. All computations relied on standard hemorrhage or ischemia, symptomatic RAO was more
software (STATA v15.0; StataCorp LP, College Station, TX, common in the OA subset with ECA (vs. ICA) dominance (p
USA). = 0.002). After CAS, OA flow in the ECA-dominant group
reverted to the ICA supply in 42 patients (56.8%).
RESULTS
Risk Factor Analysis of RAO after CAS
Baseline Characteristics of the Patient Population After CAS procedures, six patients (1.8%) developed
In total, 342 stenotic carotid lesions (men: 302/342, symptomatic RAO (central RAO, 4; branch RAO, 2), for
88.4%) were selected for this study (Table 1). The mean which older age, ulcerative plaque, and ECA-dominant OA
age of the patients was 70.0 ± 7.3 years (range, 49–87 emerged as significant risk factors in univariate analysis.
years). Symptomatic stenosis was present in 133 (38.9%) In the binary logistic regression analysis, ECA-dominant
patients, and the mean degree of stenosis was 75.5% ± OA (OR, 9.705; 95% CI, 1.519–62.017; p = 0.016) and
14.7% based on the NASCET criteria. Prior to CAS, OA older age (OR, 1.159; 95% CI, 1.005–1.336; p = 0.041)
was supplied by ECA collaterals (ECA-dominant group) were independently correlated with RAO (Table 2). Among
in 74 patients (21.6%). Bilateral CAS was performed in the six patients with RAO, five showed an OA supplied
30 patients, and staged stenting was performed in 36. via ECA collaterals (orbital branch of the MMA in all 5).
During CAS procedures, flow arrest developed in seven Baseline characteristics of these six patients with RAO are
patients who remained deficit-free. In terms of stent summarized in Supplementary Table 1.
type, an open-cell stent (254/342, 74.3%) was the most Intra-arterial thrombolysis was performed in one of
commonly applied, followed by closed-cell (85/342, the six cases of RAO. Visual symptoms improved in three
24.8%) and mixed-type (3/342, 0.9%) stents. Among patients (one after intra-arterial thrombolysis and two after
CPDs, FilterWire (218/342, 63.7%; Boston Scientific, medical management), although minor deficits persisted;
Marlborough, MA, USA) was the most commonly used, the other three patients failed to show improvement.
followed by Emboshield (72/342, 21.1%; Abbott Vascular,
Santa Clara, CA, USA), SpiderFX (32/342, 9.4%; Medtronic, DISCUSSION
Minneapolis, MN, USA), and AngioGuard (20/342, 5.8%;
Cordis Corp., Milpitas, CA, USA). Post-stent angioplasty CEA is a well-established treatment for both symptomatic
was performed for 101 lesions (29.5%). After CAS, none and asymptomatic carotid bifurcation stenosis (6-9).
of the patients exhibited reperfusion hemorrhage, but Increasingly, however, CAS has become a viable alternative
procedure-related ischemia developed in 27 patients (TIA, to CEA in some instances, especially in patients with
4; infarction, 17; RAO, 6). a hostile neck anatomy after surgery, tracheostomy, or
irradiation or in those with anatomically high lesions (10).

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 An et al.

The International Carotid Stenting Study, a randomized lesions on postprocedural diffusion-weighted imaging
study of CAS or CEA for patients with symptomatic scans (11). Despite the usage of CPDs to lessen distal
carotid stenosis, reported that in comparison with thromboembolism, debris from atherosclerotic plaques
the CEA treatment group, approximately three times may escape CPD filters and migrate into the distal cerebral
as many CAS-treated patients showed new ischemic arteries during CAS procedures. Vos et al. (1) found that

Table 1. Baseline Characteristics of Patients with Carotid Artery Stenosis Categorized by ECA- or ICA-Dominant OA Blood Supply
Prior to Carotid Artery Atenting
Univariate
Multivariate Analysis
Total ICA Dominant ECA Dominant Analysis
Variable/Group
(n = 342) (n = 268) (n = 74) Adjusted HR
P P
(95% CI)
Demographic variables
Male sex, No. (%) 302 (88.4) 236 (88.1) 66 (89.2) 0.842
Age, mean (SD), years 70.0 (7.3) 69.9 (7.2) 70.5 (7.5) 0.530
Hypertension 266 (77.8) 206 (76.9) 60 (81.1) 0.528
Diabetes 150 (43.9) 114 (42.5) 36 (48.6) 0.357
Hyperlipidemia 139 (40.6) 107 (39.9) 32 (43.2) 0.689
Smoking 131 (38.3) 99 (36.9) 32 (43.2) 0.346
Previous stroke or TIA 127 (37.1) 102 (38.1) 25 (33.8) 0.587
Coronary artery disease 91 (26.6) 68 (25.4) 23 (31.1) 0.373
Atrial fibrillation 16 (4.7) 14 (5.2) 2 (2.7) 0.538
Chronic renal failure 21 (6.1) 15 (5.6) 6 (8.1) 0.418
Angiographic variable
Symptomatic stenosis 133 (38.9) 102 (38.1) 31 (41.9) 0.591
Degree of stenosis (NASCET) 75.5 (14.7) 74.0 (15.3) 81.2 (10.7) < 0.001 1.049 (1.025–1.074) 0.001
CCA involvement 236 (69.0) 177 (66.0) 59 (79.7) 0.033 1.875 (0.956–3.675) 0.067
ECA stenosis* 72 (21.1) 56 (20.9) 16 (21.6) 0.999
Ulcerative plaque 182 (53.2) 132 (49.3) 50 (67.6) 0.006 1.988 (1.107–3.570) 0.021
Calcification 135 (39.5) 100 (37.3) 35 (47.3) 0.140
Decreased vascular reservoir† 175 (51.2) 127 (47.4) 48 (64.9) 0.028 1.207 (0.355–4.102) 0.187
Procedural variable
External pacing 57 (16.7) 42 (15.7) 15 (20.3) 0.510
Flow compromise 7 (2.0) 6 (2.2) 1 (1.4) 0.999
Stent type 0.193
Closed cell 85 (24.8) 67 (25.0) 18 (24.3)
Open cell 254 (74.3) 200 (74.6) 54 (73.0)
Mixed 3 (0.9) 1 (0.4) 2 (2.7)
CPD device 0.752
FillterWire 218 (63.7) 173 (64.6) 45 (60.8)
Emboshield 72 (21.1) 54 (20.1) 18 (24.3)
Others 52 (15.2) 41 (15.3) 11 (14.9)
Post balloon angioplasty 101 (29.5) 78 (29.1) 23 (31.1) 0.774
Outcome variable
Peri-procedural ischemia 21 (6.1) 18 (6.7) 3 (4.1) 0.585
Peri-procedural hemorrhage 0 (0) 0 (0) 0 (0) 1.000
RAO 6 (1.8) 1 (0.4) 5 (6.8) 0.002
*Stenosis of ECA origin continuous to ICA and/or CCA stenosis, †Measured by ACZ-challenge N-isopropyl-I-123-p-IMP-SPECT, and indicated
decrease of perfusion in SPECT. FilterWire, Boston Scientific; Emboshield, Abbott Vascular. ACZ = acetazolamide, CCA = common carotid
artery, CI = confidence interval, CPD = cerebral protection device, ECA = external carotid artery, HR = hazard ratio, ICA = internal carotid
artery, IMP = iodoamphetamine, NASCET = North American Symptomatic Carotid Endarterectomy Trial, OA = ophthalmic artery, RAO =
retinal artery occlusion, SD = standard deviation, SPECT = single-photon emission computed tomography, TIA = transient ischemic attack

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Symptomatic RAO after CAS

Table 2. Baseline Characteristics of Patients with or without Symptomatic Retinal Artery Occlusion after Carotid Artery Stenting
Non-RAO Symptomatic RAO Univariate Analysis Multivariate Analysis
Variable/Group
(n = 336) (n = 6) P Adjusted HR (95% CI) P
Demographic variables
Male sex, No. (%) 298 (88.7) 4 (66.7) 0.148
Age, mean (SD), years 69.9 (7.2) 77.3 (6.2) 0.013 1.159 (1.005–1.336) 0.041
Hypertension 260 (77.4) 6 (100) 0.345
Diabetes 148 (44.0) 2 (33.3) 0.699
Hyperlipidemia 137 (40.8) 2 (33.3) 0.999
Previous stroke or TIA 126 (37.5) 1 (16.7) 0.418
Coronary artery disease 90 (26.8) 1 (16.7) 0.999
Atrial fibrillation 16 (4.8) 0 (0) 0.999
Chronic renal failure 21 (6.3) 0 (0) 0.999
Smoking 130 (38.7) 1 (16.7) 0.413
Angiographic variable
Symptomatic stenosis 132 (39.3) 2 (16.7) 0.411
Degree of stenosis (NASCET) 75.5 (14.8) 77.0 (6.8) 0.806
CCA involvement 232 (69.0) 4 (66.7) 0.999
ECA stenosis* 70 (20.8) 2 (33.3) 0.610
Ulcerative plaque 176 (52.4) 6 (100) 0.032 7.233 (0.387–135.239) 0.185
Calcification 131 (39.0) 4 (66.7) 0.218
Decreased vascular reservoir† 171 (50.9) 4 (66.7) 0.240
OA supply by ECA 69 (20.5) 5 (83.3) 0.002 9.705 (1.519–62.017) 0.016
Procedure related variable
External pacing 57 (17.0) 0 (0) 0.777
Flow compromise 7 (2.1) 0 (0) 0.999
Stent type 0.999
Closed cell 84 (25.0) 1 (16.7)
Open cell 249 (74.1) 5 (83.3)
Mixed 3 (0.9) 0 (0)
CPD device 0.839
FilterWire 213 (63.4) 5 (83.3)
Emboshield 71 (21.1) 1 (16.7)
Others 52 (15.5) 0 (0)
Post balloon angioplasty 100 (29.8) 1 (16.7) 0.674
†
*Stenosis of ECA origin continuous to ICA and/or CCA stenosis, Measured by ACZ-challenge N-isopropyl-I-123-p-IMP-SPECT, and indicated
decrease of perfusion in SPECT.

emboli could be detected using transcranial Doppler by CPDs during treatment displayed new retinal emboli,
sonography during wiring and passage across the stenosis, whereas 2 of 23 patients (9%) undergoing unprotected
predilation, stent placement, postdilation, and use of an procedures developed RAO. This suggests that CPDs placed
embolic protection device (EPD). Isolated emboli were at the ICA cannot completely filter the atherosclerotic
most common during wiring and stent deployment, whereas debris loosened from plaques during CAS, or the blood
embolic showers were primarily detected during stent flow during balloon angioplasty may flush the debris
deployment and postdilation. toward the retinal artery via ECA collaterals. Wilentz et al.
RAO is one of potential complications of CAS. Because it (12) also reported the presence of RAO after CAS using a
is not a common complication, the mechanisms underlying distal ICA balloon system as CPD. As described, 5 of 38
post-CAS RAO are not well documented. In these cases, patients (13.2%) who underwent the Theron approach
embolic debris may originate from both the ICA and ECA. (routine flushing toward the ECA) developed emboli, in
According to Vos et al. (1), 3 of 10 patients (30%) shielded comparison with 1 of 80 (1.25%) who were protected with

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 An et al.

the PercuSurge system (aspiration only; Medtronic) (p = (15%), all of which proved asymptomatic. Fortunately, most
0.019). Thus, embolic sources contributing to RAO are apt retinal emboli are clinically silent (15). Wilentz et al. (12)
to migrate via ECA collaterals. have also reported a 5.1% (6/116) incidence of RAO after
In the present study, RAO after CAS showed a significant CAS, whereas the incidence of symptomatic RAO was just
relationship with OAs supplied by ECA collaterals prior 1.7% (2/116). In our series, the incidence of symptomatic
to CAS (i.e., at baseline) and older age. In addition, OAs RAO following CAS was 1.8%, which is consistent with the
supplied by ECA collaterals prior to CAS were linked to outcomes of other studies.
severe ipsilateral ICA stenosis. Hence, OAs may be mainly Certain limitations of this study need to be acknowledged.
supplied by the ECA in patients with severe ICA stenosis First, this was a retrospective observational study with
and in such patients, debris from the atherosclerotic plaque few occurrences of symptomatic RAO, despite the large
may migrate to the ECA via collaterals during balloon sample size. In addition, the stents and distal filter systems
angioplasty (with the ICA blocked and the filter in the ICA). used as CPDs were not standardized. Furthermore, the
According to the literature, anastomosis of the external ophthalmologic examinations stipulated were not routinely
carotid circulation to the distal ICA (e.g., orbital branch of performed in all patients with CAS. Only those experiencing
the MMA or STA to the OA) or OA flow reversal takes place visual symptoms after CAS underwent the required battery
in instances of severe carotid stenosis (3-5, 13). Debris of studies.
passing through these collaterals leads to RAO and should In conclusion, the incidence of symptomatic RAO after
be taken into consideration (12). In cases of OAs supplied CAS was low (1.8%) in our population. However, because
by the ECA, the lack of an EPD to filter debris at the ECA reversal of OA flow to the ECA (established prior to stenting
may also lead to RAO during CAS. The strength of our of severely stenotic ICAs) proved independently predictive
research is the premise of ECA-dominant OA flow. Indeed, of symptomatic RAO after CAS, caution should be exercised
we have now demonstrated a significant relationship in this setting. For older patients, the use of simultaneous
between ECA-dominant OA flow and symptomatic RAO. Thus, ICA-ECA CPDs may help prevent such complications.
to avoid RAO as a procedural complication, it is vital to
check whether the OA is largely supplied by the ICA or ECA Supplementary Materials
prior to CAS.
Given the above revelations, any currently popular distal The Data Supplement is available with this article at
filtering system that is placed in the ICA cannot completely https://doi.org/10.3348/kjr.2019.0030.
prevent RAO after CAS. The Mo.Ma model (Medtronic) is
one type of proximal CPD that works by blocking flow in Conflicts of Interest
a target vessel through balloon occlusion of the ECA and The authors have no potential conflicts of interest to
CCA. In patients with severe stenosis plus ECA-dominant disclose.
OA supply, the Mo.MA CPD may prevent RAO after CAS
by averting the rush of debris into ECA collaterals and ORCID iDs
permitting suction removal. One drawback of this device Young Dae Cho
is occlusion intolerance, which occurs at a rate of 12% https://orcid.org/0000-0002-5293-2761
(14). However, if collateral circulation through the Circle of Sang Joon An
Willis is sufficient, the Mo.Ma CPD may be a good option for https://orcid.org/0000-0002-6022-6058
preventing RAO in this particular context. Jeongjun Lee
The incidence of RAO after CAS varies across reports, of https://orcid.org/0000-0001-6847-1130
which there are few. Song et al. (2) reported a 4.9% rate Jong Hyeon Mun
of RAO in their CEA group (n = 61), unlike the much higher https://orcid.org/0000-0002-3380-9944
16.9% rate in their CAS group (n = 71) (p = 0.031). In the Dong Hyun Yoo
aftermath of CAS, 12 patients exhibited RAO, but only a https://orcid.org/0000-0003-1658-5341
single patient experienced diminished visual acuity or visual Hyun-Seung Kang
field (incidence of symptomatic RAO, 1.4%). According to https://orcid.org/0000-0002-6957-1907
Vos et al. (1), RAO occurred after CAS in 5 of 33 procedures

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Symptomatic RAO after CAS

Yun-jung Yang patients with symptomatic moderate or severe stenosis.

https://orcid.org/0000-0002-3006-1897 North American Symptomatic Carotid Endarterectomy Trial
Collaborators. N Engl J Med 1998;339:1415-1425
Moon Hee Han
9. Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter
https://orcid.org/0000-0001-5476-3482
J, et al.; MRC Asymptomatic Carotid Surgery Trial (ACST)
Collaborative Group. Prevention of disabling and fatal strokes
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