How to Optimize Carotid Artery Stenting: by Trans ... - summitMD.com

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How to Optimize Carotid Artery Stenting: by Trans ... - summitMD.com

How to Optimize Carotid Artery Stenting: by

Trans-Femoral, Trans-radial radial or Brachial

Chiung-Jen Wu & Interventional Teams of

Chang-Gung Memorial Hosp.,

Kaohsiung, Taiwan

Apr. 23, 2008,

TCT Asian-Pacific &

Angioplasty Summit 2008

1


Limitations for TF Carotid Stenting

• Level II-III III aortic arch

• Bovine arch (Lt & Rt CCA from a main trunk)

• Aortic arch branch ostia stenosis or arch anomaly

(Kommerell’s diverticulum: : LCCA from AsAo)

• Tortuous or occlusion of ilio-femoral or

abdominal aorta

• Morbid obesity

• Spinal/hip problem, BPH & etc: intolerable long bed rest

after PTA/stenting


A 72 y/o male, DM, H/T, old CVA h/o Rt ECA-ICA anastomosis,

critical stenosis at Rt ECA-os & Lt ICA, referred from Neuro-Surgeon

LAD mid-distal 70%

tandem lesions

Lt Ext. iliac A total occlusion

Rt ext. Iliac A diffuse

60% stenosis

Rt femoral A long total

occlusion


S/p T-R two Magic-Wall stenting in Rt ECA-os (h/o ECA-ICA

anastomosis) & Lt ICA 80% stenosis with Lt MCA occlusion

Rt ECA-os

s/p M-Wall

stenting via a

6F K-R

guiding

Lt ICA 80%

stenosis

Lt MCA total


Aortic arch anomaly

Kommerell’s Diverticulum

LAO-15 degree

True

Lateral

AP view

Lateral Bovine Arch


TR coronary & selective cerebral

angiography: CGMH study

• Coronary angiography were selected with a 6F Kimny-

mini-Radial guiding catheter (Boston) & others

• Selective cerebral angiography were performed with K-K

R (either directly or looping in AsAo), 5F JB (Cordis(

Cordis), 5F

Viteck (Cook) or 5F Simon catheters

• Cocktail (Verapamil(

5 mg, Heparin 5,000 iu & NTG 200

ug) ) was given after radial access

• Hemostasis after TR procedures: “figure of 8” 8 adhesive

tape

• 2-44 hrs observation in Cath. Room for OPD pts

CJ Wu, Yip HK. Catheter Cardiovasc Int. 2005: 66; 21-26

26


Case CGMH-1 Chen L.O. 65 y.o male

Target Lesion: Bil. carotid A.

Trans-radial Approach

Diagnosis: carotid bruit, H/T, TIA

Present illness:

’05.9.14 LMT-stent (Taxus 3.5x20 mm)

Lt Common carotid-os 73%

Lt subclav. 70%, Lt VA 100%

Rt VA small vessel

Rt Internal carotid 76%

Coronary risk factors:

H/T, hyper-lipidemia

Final CAG findings: ’05.9.14

LMT 70%, LAD-mid 60%

Rt ICA 76%

stenosis

Lt CCA-os

73% stenosis


Conclusions: TR cerebral angio.

• Simultaneous coronary & cerebral angiographies

are feasible & safe by using trans-radial radial approach

(OPD or in-patient) in experienced operators

• TR selective cerebral angio. . has high successful

rate 93% & very low complication rate 4.7% (r/o(

TIA in 2 with complete recovery)

• Presence of significant carotid/ cerebral A

stenosis is associated with very high incidence of

CAD (82.9%)

CJ Wu, Yip HK. Catheter Cardiovasc Int. 2005: 66; 21-26

26


Case Presentation for TR-CAS

• A 65 y/o male with HCVD & hyper-lipidemia

lipidemia,

c/o DOE for one yr, asymptomatic neck bruit was

found on P.E. with transient black-out (TIA ?)

• s/p Carotid Doppler study: severe stenosis over

Rt internal carotid artery

• Echocardiography: normal chamber size,

adequate LV performance, Gr 2/4 mild AR

• Admitted for Dx coronary angiography &

selective cerebral angiography without stress test

for myocardial ischemia


A 65 y/o male, HCVD with hypercholesterolemia, Rt carotid bruit

6F Mach-1

Kimny-mini-Rad.

Lt CCA-os 73%

eccentric stenosis

MLD = 1.94/7.3 mm

Lt subclavian

70% stenosis & 80

mmHg gradient &

Lt VA total occlu.

Rt small VA with

insignificant stenosis

Rt ICA-ECA bifurcation 76%

ulcerative stenosis MLD = 1.48/6.3 mm


A 65 y/o male, HCVD with hypercholesterolemia, Rt carotid bruit

Lt intra-cranial vessels AP-cranial & Lat.

Rt intra-cranial

vessels

Collateral from postcommunicating

A.

Lt CCA-os 73%

stenosis, Left ICA-

ECA bifurcation OK


A 65 y/o male, Rt carotid bruit, critical LMT asymptomatic

LAD-mid 65%

tubular stenosis

Sep.-14, 2005


Final angiography LMT-LAD Taxus 3.5x20 mm cross-over


LAD-os MSA = 11.3 mm2

LMT-dis MSA = 13.4 mm2

LAD-LCX bifurcation

D1 = 4.4 mm

D2 = 3.7 mm


Sequential POBA & Express-SD 6x19 mm stenting for Lt CCA-os via

Trans-brachial approach (12 days later after LMT-stenting)

3x20 Gazelle POBA

at 12 atm

LCCA-os 73%

eccentric stenosis

EZ-filter dis. Protection

Express-SD 6x19 mm

stenting at 16-18 atm

s/p LCCA

stenting nonselective

angio.


Same stage Rt internal carotid stenting (Carotid-Wall 9x40 mm)

Rt ICA ulcerative plaque

75% stenosis

0.014x300 cm extrasupport

& Percurge

balloon 5.5 mm in Rt

ECA for anchoring

3rd wire

0.035x260 cm

Tefron-coat for

advancing a 7F

K-R guide in

RCCA

PTA 4x20 mm Gazelle

at 10 atm

s/p stenting PTA

6x20 mm at 10 atm


Coronary angio. . F/U 6-mo 6

later

• Left main s/p Taxus stenting without ISR

• Lt CCA-os

stenting no ISR

• RCCA-ICA

stenting no ISR

• Left subclavian artery long tubular 70% stenosis

with 80 mmHg gradient s/p PTA & Express-LD

6x37 mm stenting with final in-stent portion 8x20

mm PTA at 14-16

16 atm


Indications & Techniques of TR/TB CAS

• Symptomatic including TIA, ischemic stroke with

significant ICA stenosis ( ≥ 50% DS), Asymptomatic pts

with ICA stenosis (≥ 70% DS)

• Interven. . For TR/TB approach (looping(

technique):

1) a 6F Kimny-Radial guiding engaging CCA either by

direct selection or wire-assisted looping technique,

2) a 0.014 PercuSurge-Guard wire in ECA for anchoring

3) a 2nd wire 0.035 x 260 cm Tefron-coated in CCA,

4) Exchange 6F K-R K R to 7F coronary guide looping in

AsAo & catheter tip in CCA

5) Heprine 5,000 iu routinely with distal protection either

by Filter or Percusurge-GW routinely


TB-Rt carotid stenting for Level-

2 aortic arch with looping

technique for Rt ICA stenting

(failed T-F CAS)

3x20 Gazelle

POBA

Carotid-Wall 10x31 mm &

6x20 mm Gazelle at 12 atm


Direct selection:

via Rt radial or

brachial approach

with 6F K-R &

exchanging to 7F

for routine CAS


Devices for Carotid Stenting

FilterWire EX ® /EZ

Carotid WALLSTENT®

Monorail®

• Monorail delivery system

• Suspended radiopaque nitinol loop

• 0.014” Embolic Protection Guidewire

• Filter pore size = 110 microns

• Fits 3.5-5.5 mm vessels

• 190cm & 300cm lengths

• Monorail delivery catheter

• Self-tapering elgiloy

• 5.0-5.9 F

• Diameters: 6, 8, 10 mm

• Lengths: 20, 30, 40 mm

• Closed cell design


TF vs TR/TB Carotid Stentings

• TF Gr: : 38 pts (38 stenting) ) using distal protection

dominantly by Percusurge-Guard wire device

• TR/TB Gr: : 115 pts (113 stenting), 2 pts with PTA

for Intracranial-ICA ICA were excluded

• TR stenting without protection in 2 pt (h/o(

Rt ICA

total occlusion with ECA-ICA bypass & developed

CCA-ECA junction critical stenosis, , 2nd pt had

360 degree turn ICA after critical stenosis, , failed

Percusurge Guard-wire passing)

• TR/TB later period using dominantly Filter for

distal protection

CJ Wu, Yip HK. Catheter Cardiovasc Int. 2006: 67; 967-971

971


Results (I): TF vs TR/TB Carotid stentings

• From Mar. 2003 to Apr. 2008: consecu. . 151 pts enrolled

TF (38) TR/TB (113)

P value

Sex (F/M) 6/32 16/97 N.S.

Age (y/o(

y/o) 70.2 ± 8 71.6 ± 8.3 N.S.

B.H. (cm) 161 ± 4.7 161.1 ± 7.3 N.S.

B. W. (Kg) 65.5 ± 12.2 65 ± 11 N.S.

DM 43% 34% N.S.

H/T 80% 85% N.S.

Curr.smoker 33% 35% N.S.

Hypercholes. 25% 33.3% N.S.


Results-II: Carotid Stenting & PTAs

TF (38) TR/TB (113)*

P value

Access A. RFA 38 TR 57/ TB 56

Access T. (min) 2.37 ± 2.4 2.38 ± 2.1 N.S.

Dx T. (min) 18.7 ± 6.2 22.8 ± 11.3 N.S.

Proced. . T. (min) 60.1 ± 27.5 75.1 ± 28 N.S.

Fluoro. . T (min) 16.0 ± 5.9 24 ± 11.8 N.S.

Contrast V. (ml) 175.9 ± 32.4 208.9 ± 69.4 N.S.

* TR/TB: via Rt 50/113 (44.2 %) vs Lt 63/113 (55.8 %) approach

* TB PTA aborted 1 due to exchanging failure of 6F to 7F guiding


AP

view

Rt carotid A. Left carotid A.

ESRD with old

CVA, Variant of

Rt ECA anatomy

Lat.

view


Anchoring with

PercuSurge to the

mandibular branch

of the Rt ECA


Puncture site complications: Left brachial

Pseudoaneurysm at 2 days later, required surgical

repair


Results-III: Carotid stenting & PTA angio. . results

Carotid A. TF (38) TR/TB (112)

P value

RCCA/RICA 18/38 55/112 (49.1%)

LICA 20/38 57/112 (50.9%)

Lesion L. (mm) 17.3 ± 3.2 17.2 ± 5.8 N.S.

Pre-DS (%) 76.1 ± 9.5 % 75.9 ± 9.7 % N.S.

Pre-MLD (mm) 1.34 ± 0.64 1.26 ± 0.55 N.S.

Pre-refer. refer. (mm) 5.49 ± 1.06 5.22 ± 0.98 N.S.

Post-DS (%) 21.3 ± 7.0 % 16.2 ± 10.1 % N.S.

Post-MLD (mm) 4.56 ± 0.55 4.4 ± 0.8 N.S.

Post-refer. (mm) 5.97 ± 0.87 5.33 ± 0.91 N.S.

Percu./Filter

22/16 8/102 P < 0.01

Fin.Ballo.(6mm) 27/38 (71.5%) 78/112 (69.6%) N.S.

Direct stenting 17/38 (44.7%) 56/112 (50%) N.S.


CAS Complications (per procedure):

• No major stroke, ICH, MI, nor death at 30-days

• TR/TB 30-d d death/stroke = 3/112 (2.7%) including 1 minor

stroke (multiple emboli) at 24-hr after stenting

• TR/B Gr.: unfavorable anatomy for TF CAS (Bovine arch,

Level 2-32

3 arch, tortuous or total ilio-femoral) = 19/112

(17%), high risk for CEA = 80/112 (71.4%)

• Hyper-perfusion perfusion syndrome in 1 (TF: conscious change

with status epilepticus required ventilator support &

general anesthesia), complete recovery without sequela

• Hosp. stay were no difference TF vs TR/TB:

6.3 ± 6.1 vs 7.6 ± 5.5 days

• pseudo-aneurysm occurred in 2/56 (3.6%) T/B pts


Conclusions for TR/TB CAS:

• Routine TR/TB CAS is safe & feasible in our experience,

with very high success rate 112/113 (99.1%)

• Other reports were rare with success rate of 35/42 (83%,

CCI 2007;69:355) & 24/27 (89%, J vasc Surgery

2007;45:1136), easily failed at LICA lesions, but by

looping technique in our study 57 CAS of LICA are all

successful

• Looping technique, telescoping access combining with or

without balloon anchoring is feasible for RICA/LICA

• RRA/RBA direct selection with telescoping access for

RICA, or bovine arch with LICA lesions

• Learning curve from TR/TB Dx cerebral angio. Then

advancing for TR/TB CAS, which is most useful for

trans-femoral difficult or failure cases


Thanks for Your Attentions !


Carotid Stenting with

Complex Lesion Carotid

Anatomy

Revisit after 2 failed trials

Operator : Dr Chiung-Jen

Wu


History

72 year old female

h/o Old right side hemiplegia with history of

recent TIAs of weakness of right limbs

Her Daily life activities were partially

dependent

CAD Risk Factors : Hypertension

Diabetes Mellitus

Dyslipidemia

Past H/o CABG 5 years back : LIMA to D1

SVG to OM2

SVG to LAD


Previous Interventions

Carotid Stenting was advised by Neurologist

Failed Left internal Carotid artery Stenting 2

times by femoral approach by Neuro-

Radiology

Patient was referred for Surgery due to

Complex Anatomy of left ICA but Surgeon

refused to operate because of her poor general

condition with h/o CABG

Referred to us for attempt Carotid stenting


Strategy

General anesthesia for poor cooperation

As a routine of any Carotid PTA, we start

with coronary angiography

Left high radial approach

Patient had history of CABG with LIMA to

D1(any intervention could also be treated in

same setting)

Shift to femoral if unsuccessful


Coronary Angiography

RCA Total

SVG to LAD

SVG to OM 2


Left CAG

AVI

LCX Lesion


Maverick 2.0x20mm at 12 atm

Zeta Stent 3.5x33mm at 16atm

Quantum3.75 at

16atm


PCI to Proximal LCX

AVI

Post Stenting Kissing

Balloon


Tortous RCCA with no significant lesion

Kimni Looping In Aorta

AVI

RCCA Engaged with 6 Fr Kimni


360 Degree looped LICA with

Subtotal Occlusion

AVI

AVI


Delayed flow in

Left Intra-cranial portion

AVI

Right Intracranial :

normal


Exchange of 7 Fr Kimni-Rad with

Anchoring of PercuSurge in ECA

PercuSurge Anchor in

ECA

AVI


Pre-dilatation

PercuSurge body wire failed

to cross 360 degree bend of

ICA

Maverick 2.0x20mm at 12

atm


Predilatation with Maverick 3.5 x20mm

Balloon at 14 atm


Post Dilatation

AVI

Maverick 4.5x20mm at 14 atm

with PercuSurge Anchor In ECA


Wall Stent failed to advance even by anchoring of

PercuSurge Balloon

AVI

Stent

Maverick 3.0x20mm in ECA

Balloon Expandable Stent advanced by Anchoring Maverick 3.0

balloon in External Carotid Artery


Stent Deployed by Anchoring

AVI

Technique

AVI


Post Dilatation

AVI

AVI


AVI

AVI

AVI


Intracranial

AVI

AVI


Discussion: complex CAS

• Balloon Expandable stents in Carotid artery

are not protected by axial skeleton and can

easily gets compressed by external force

• High chances of restenosis.

• But in this patient with large number of

comorbid condition , physical inactivity,

relatively short life span and dependent daily

life activities, we deployed Balloon expandable

stent as Wall stent failed to advance and

Surgery was very high risk.

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