Transcript Carotid Stent Technique Dx

Carotid Stent Techniques
Michael J. Cowley, M.D. FSCAI
Carotid Stent Technique
Basic Equipment
• Angiography (pigtail, access catheter)
• Stiff hydrophilic guide wire (0.035”)
• Long interventional sheath or guide catheter
• Embolic protection device
• Appropriate size balloon catheter
• Self-expanding (FDA approved) carotid stent
• Closure device (optional)
Carotid Stent: Target Lesion Location
ICA alone: 3%
Bifurcation: 90%
CCA alone: 5%
Multiple: 2%
Carotid Stent Technique
Fundamental Steps
•
•
•
•
•
•
•
•
•
•
•
Femoral access
Arch angiography
Selective catheterization of target CCA
Wire placement in ECA
Sheath or GC placement in distal CCA
Placement of embolic protection device
Pre-dilation of lesion
Stent placement
Post-dilation of stent
Removal of EPD
Final angiography
Carotid Stenting
Need for complete inventory
Diagnostic Catheters
• Vitek
• Simmons 1 and 2
• Headhunter
• Davis
• Berenstein
• HN2
• Others
Guidewires
• 0.035” exchange glidewire
• 0.038” exchange glidewire
• 0.035” Amplatz SS (1cm vs 4cm
floppy)
• Wholey exchange
• 0.035” Rosen
• 0.014 Spartacore
• SV 14/5
• 0.018” Roadrunner
Bovine Arch
Work-horse Guides
Simple Curved
Catheters
‘Coronary catheters’
IMA
Modified AR1
JR 4
Consider using
dedicated catheters!!!
Complex Curved Catheters
Simmons 1, 2, and 3
curves
VTK
Wires Selections:
Soft, Stiff, and Variable Diameters
- 0.035” Rosen wire
- 0.035” hydrophilic wire
- Straight extra-stiff
300 cm Amplatz wire
- TAD wire (0.018”0.035”) w/ DOC
- 0.038” extra-stiff Glidewire ideal for VTK
catheter
- 280 cm Magic Torque
- 0.014” buddy wires
(Sparta-Core, BMW)
Access Strategy
Determined by:
• Arch Anatomy
• Common carotid anatomy
• Anatomy of the lesion
• Patency of external carotid artery
• Anatomy of internal carotid distal to
the lesion
Arch Aortogram
• 30-40 LAO view
• Field of view should include origin of
great vessels and extend to include
the carotid bifurcation
• Patient’s head should be straight
with chin turned upward
Carotid Angiography
• Ipsilateral oblique and lateral views
(additional views may be necessary)
• Contralateral carotid (Circle of Willis,
collaterals, etc)
• 5 or 6 F with appropriate curve
• Intracranial angiography also important
Carotid Angiography
Key features
• Site of stenosis
• Presence of ulceration
• Bifurcation involvement
• Severity of stenosis
• Landing zone for EPD
• Lesion length
• Patency of ECA
• Degree of calcification
• Presence of ICA
tortuosity
• Presence of thrombus
Intracerebral Angiography
• Anterior cerebral circulation viewed by PA cranial
(15-20 degrees) and lateral views
• Important to visualize both arterial and venous
phases:
- Intracerebral disease
- Collateral circulation
- Presence of AVM, aneurysm, isolated hemisphere
- Missing arterial phase vessels
(allows identification of embolization post CAS)
Carotid Stent Technique
Guide Catheter Placement
• Dx catheter engages innominate and road
map of carotid bifurcation done
• Stiff angled 0.035’ guide wire advanced
into distal CCA or ECA under roadmap
guidance
• Diagnostic catheter exchanged for guide
catheter
• Guidewire removed
Carotid Stent Technique
Guide Catheter Placement
• Long (125 cm) diagnostic catheter telescoped
through 8F GC
• Roadmap view (preferably lateral) to visualize
bifurcation of ECA and ICA
• Stiff, angled 0.035 hydrophilic wire advanced into
ECA using roadmap guidance
• Dx catheter advanced over wire into distal CCA
• GC advanced over wire/Dx catheter into distal CCA
• Diagnostic catheter and wire removed
Carotid Stent Technique
Sheath Placement in CCA
• Diagnostic catheter (125 cm) engaged in innominate or
LCCA
• Roadmap view (preferably lateral) to visualize
bifurcation of ECA and ICA
• Stiff, angled 0.035 hydrophilic wire advanced into ECA
using roadmap guidance
• Dx catheter advanced over wire into the ECA
• Guide wire exchanged for super stiff (1 or 6 cm soft tip)
• 6F sheath advanced into CCA over guidewire
• Guidewire removed
Carotid Stent Technique
Guide Catheters
Advantages
Disadvantages
• Better torque control
• 8 Fr sheath size
• More rigid; better
support
• Uneven transition with
inner catheter
• Better for tortuousity
• Many pre-formed
curves available to fit
anatomy
Carotid Stent Technique
Long Sheath System
Advantages
Disadvantages
• 6 Fr sheath size
• No torque control
• Integrated dilator
provides smooth
transition
• Less rigid; less
support
• Less favorable for
tortuous anatomy
• More likely to slip
back during EPD or
stent delivery
Carotid Stent Technique
Working View
Carotid Stent Technique
Distal Protection Devices
Filter Wire EX
80-110µ pore size
AngioGuard XP
100µ pore size
ACCUNET
≤150 µ pore size
Filters: Newer Devices
Emboshield
FilterWire EZ
Interceptor
Rubicon
SPIDER
Carotid Stent Technique
Distal Protection Placement
• Advance EPD across lesion and filter in
distal ICA in straight segment belong
siphon
• Buddy wire may guide catheter with
angled tip may be needed if angulation
and tortuousity present
• Percusurge is option if difficult passage
for filter device
Carotid Stent Technique
Pre-dilation
• Preferable to assure stent delivery and
adequate stent expansion
• May provide information on hemodynamic
response to carotid sinus stimulation
• Helpful for assessment of lesion length
and reference vessel diameter
• PTCA balloon 4mm x 20-40 mm long
• Brief inflation to eliminate indentation
• Slow deflation may reduce embolization
Carotid Stent Technique
Stent Placement
• Flush central lumen and lock stent connector
• Advance stent delivery system over EPD shaft
past lesion site (do not advance against
resistance)
• Position stent in lesion by pulling back SDS until
radio-opaque shaft markers are proximal and
distal to the lesion
• Positioning facilitated by use of bony landmarks,
roadmap image, and contrast injection
• Deploy according to IFU for particular stent
Selection of Carotid Stent
• Stent diameter
• Tapering vs non-tapering vessel
• Oversize largest “target” by 1-2mm
• Stent length
• Cover “shoulder-to-shoulder”
• Avoid stent edge in bends
• When in doubt, use longer stent
Carotid Stent Technique
• Post dilate to achieve adequate lumen (5
mm or 6 mm balloon)
• Assess final result and distal flow
• Remove EPD if satisfactory flow
• If slow flow, determine cause
• spasm, dissection, full filter
• Aspiration with export catheter or Pronto
catheter before removal if filter full
Carotid Stent Technique
Final Angiography
• Carotid Angiography:
- evaluate target lesion status
- stent expansion
- distal runoff
- evidence of spasm or dissection
• PA and lateral intracranial views
- exclude evidence of embolization
Carotid Stenting
Intraprocedural Medications to Have Available
Pressors
Anti-thrombotics / lytics
Neosynephrine drip
Heparin
Levophed drip
IIb/IIIa inhibitors
Aramine
Retavase, tPA, Urokinase
Vasodilators
NTG
Nipride
Anticholinergics
Atropine
Carotid Stent Techniques
General Guidelines
• Don’t force!!!…if not advancing easily
select another shape or rethink your
treatment options
• Don’t start CAS with suboptimal support…
• like coronary work, the time to find out
you can’t do it is not in the middle of the
case (especially with distal protection)
Carotid Access Issues
• Complications dependent on:
- Symptomatic vs asymptomatic status
- Duration of catheter in cerebral arteries
- Number of catheter exchanges
- Number of vessels cannulated
- Contrast volume, fluoro time
• At present appropriately patients for CAS are all
“high risk” for anatomic or clinical reasons
• Target high risk clinical with low risk anatomic
features in your initial experience
Largely determined by case selection
®
6.5 F Slip-Cath
125 cm
H1, JB 1
.085” OD
6F Shuttle Sheath
Shuttle Select™ System
Bovine Arch
Work-horse Guides
8F Guiding Catheter &
120 cm 6F Diagnostic Catheter
VS.
Shuttle Select™ System
Arch Aortogram:
A ‘Dry Run’ for Carotid Stenting
Evaluate:
- Access site, iliacs
- Arch configuration and appropriate
catheter/wire combinations for arch
cannulation
- Assess possible sheath placement
challenges
- Best angles to highlight carotid
bifurcation, DP landing zone, etc.
Carotid Access Issues
• Complications dependent on:
- Symptomatic vs asymptomatic status
- Duration of catheter in cerebral arteries
- Number of catheter exchanges
- Number of vessels cannulated
- Contrast volume, fluoro time
• At present appropriately patients for CAS are
all “high risk” for anatomic or clinical
reasons