**11.1 Sentinel CEPD**

This device is the most studied CEPD and only FDA-approved device for commercial use. It can be implanted through a 6-French sheath through a radial or brachial access. There are two filters in the delivery system. One filter is to be placed in the brachiocephalic trunk and the other is placed in the left common carotid artery. With this the left subclavian artery is not covered. Therefore, there is not a complete cerebral protection with this device. There have been a few clinical trials comparing the Sentinel to unprotected groups. The CLEANTAVI and MISTRAL-C randomized controlled trials showed a reduction in the amount of new ischemic brain lesions in the protected areas in the Sentinel versus the unprotected groups. The PROTECTED TAVR trial studied whether TAVR reduces the risk of periprocedural stroke with CEP use. This was a large, randomized, prospective trial in which CEP was successfully deployed in 94.4% of patients. The results showed that the incidence of procedural complications did not differ significantly between patients who underwent TAVR with CEP versus without CEP. However, there was a 95% confidence interval with the outcome therefore it did not rule out the overall benefit of use of CEP in TAVR procedure [60].

### **11.2 TriGUARD embolic deflector device**

This system contains a single-use, biocompatible filter mesh. It can be implanted through a 9-French transfemoral sheath using fluoroscopy to be deployed in the aortic arch. This device covers the right brachiocephalic, left common carotid, and subclavian artery. Therefore, it prevents cerebral embolization by redirecting the debris to the descending aorta. The device is stabilized in a stable position by being anchored in the right brachiocephalic artery ostium. The TriGUARD's safety was initially confirmed in the DEFLECT 1 trial as it also showed 80% of patients had successful coverage of all three branches. The second-generation of this device, TriGUARD HDH was invented and then also evaluated in other studies. The DEFLECT III trial showed less neurological deficits as defined by the National Institutes of Health Stroke Scale (NIHSS) and cognitive function improvement [59]. *TriGUARD 3* is an update of the current TriGUARD HDH that provides easier usage, extensive coverage of all three major branches, and less interference with the TAVR. This device contains a biocompatible nitinol filter mesh which has a smaller pore size compared to the previous TriGUARD HDH which helps prevent smaller particles from getting into the cerebral circulation. It can be delivered through an 8- French transfemoral sheath. This device does not need a stabilizer as there is enough stability offered through the nitinol shaft and from the circumferential device pressure from the aortic arch. The REFLECT II trial proved that the TriGUARD group had higher safety when compared to the unprotected group (15.9% vs. 7%). This study had successful device positioning in 59.3% of the patients [59].
