CAROTID STENTING StepbyStep Technique Stephen Ramee MD and
CAROTID STENTING: Step-by-Step Technique Stephen Ramee, MD and Tyrone J. Collins, M. D. Interventional Cardiology Ochsner Medical Center New Orleans, LA
Stephen R. Ramee, MD § Contracted Research / Grant Support: § Cordis Corporation § Consulting Fees: § Access. Closure, Inc.
Stephen R. Ramee, MD § Ownership Interest (Stocks, Stock Options, or other Ownership Interest): § Square. One § I-Therapeutics Corporation § Hot Spur § Lazarus Effect § Honoraria: § Sadra Medical
Ochsner Carotid Stent Team Gabby Laurie Chip Ramee White Ken Tyrone Ochsner Heart & Vascular Institute
Carotid Stent Equipment 6 Fr. or larger 90 cm sheath 8 Fr. or larger guiding catheter Guidewires 0. 014 x 180 cm BMW, S’Port, Choice PT XS 0. 035 x 145 cm Zip wire, Glidewire 03035 x 300 cm Amplatz XS straight or Supercore 4. 0 -5. 0 x 20 -30 mm 0. 014 mm balloons Self-expanding carotid stents
Dual-Plane Lab • Dual inch image intensifiers • One digital unit • Dedicated slave monitor • • Digital angiography Digital subtraction Roadmapping Archival storage
Carotid Stenting: Technique Angiography Access to the common carotid artery Placement of protection device Predilating Deploying the stent Post-dilating the stent Protection device retrieval and final angiography
Carotid Stenting: Technique Angiography Access to the common carotid artery Placement of protection device Predilating Deploying the stent Post-dilating the stent Protection device retrieval and final angiography
Aortic Arch Anatomy
Aortic Arch Anatomy
Angiographic Technique • Use digital subtraction for most diagnostic images. • Use non-subtracted views for ostial lesions, calcified lesions and intervention. • For aortic arch angiograms…use 45 deg. LAO and have the patient’s head looking at the image intensifier. • Avoid the Panhandle Rollercoaster: Don’t pan during injections. • Frame rate between 3 -10 frames per second.
Carotid Stenting Technique Aortogram Pigtail catheter Digital subtraction Largest field of view possible
Aortic Arch Types Type III
Simple Carotid Anatomy
Type I - “Simple Aortic Arch”
Type III “Difficult Aortic Arch”
Carotid Stenting: Technique Angiography Access to the common carotid artery Placement of protection device Predilating Deploying the stent Post-dilating the stent Protection device retrieval and final angiography
Tool Box: Diagnostic Catheters Ø 4 or 5 Fr catheters Ø 0. 035 Hydrophilic wires ØRegular & XS
Diagnostic Angiography Maxims • As with coronary disease, one can’t INTELLIGENTLY manage cerebrovascular disease without knowing the anatomy. • You need to image the entire cerebral and vertebrobasilar anatomy, non-invasively or angiographically. • Collateral pathways have important implications. • You DON’T need to engage the vertebral arteries, especially the right, selectively to have a complete study. Use subclavian injections. • Make sure you image the vertebral artery origins! • Keep catheter manipulation to a minimum.
Carotid Artery Stenting Catheters for Angiography and Access Simmons Berenstein Judkins Right Vitek Amplatz
Berenstein
Vitek
Simmons
Carotid Access: Summary
6 Fr. Sheath
Technique 1: Exchange 4 -5 Fr. Catheter through femoral sheath . 035” angled glidewire to External Carotid Advance diagnostic catheter into ECA Exchange fro. 035” Amplatz extra-support wire and remove diagnostic catheter Insert sheath/guide over Amplatz wire and advance as unit from FA to CCA
Exchange Technique
Exchange Technique
Exchange Technique
Technique 2: Coaxial Access 5 Fr. Catheter (125 cm) through sheath/guide to engage CCA or Innominate Artery . 035” Extra stiff angled glidewire to distal Carotid artery Advance 5 Fr. Catheter to ECA Exchange for. 035” Amplatz XS wire Advance sheath/guide coaxially over 5 Fr. Catheter and Amplatz wire to CCA
Coaxial Technique
Coaxial Technique
Coaxial Technique
Exchange Technique
Baseline Angiography
Access External Carotid
Xtra Stiff Wire Placed in External Carotid
Sheath Inserted and Wire Removed
When Is an 8 Fr Guiding Catheter Preferred? Complex Arch Anatomy Calcified aortic arch Elongated aortic root Aorto-ostial lesions Tandem lesions Bovine arch (left carotid) Tortuous common carotid Tortuous iliacs
Wire in the ECA
Guide brought over the wire
Guiding Catheter at innominate origin
Q. What should I do if I have tried everything and still cannot get my guiding catheter or sheath into the common carotid artery? Ochsner Heart & Vascular Institute
Carotid Stenting: Technique Angiography Access to the common carotid artery Placement of protection device Predilating Deploying the stent Post-dilating the stent Protection device retrieval and final angiography
Use Embolic Protection Flow Blockage by distal ICA Occlusion Distal Flow Blockage Percu. Surge Guard. Wire Distal ICA Filtering Endovascular Clamping by CCA and ECA Balloon Occlusion Antegrade Flow Angio. Guard Embo. Shield EPI Filter. Wire Spider CV 3 Accunet Fibernet Proximal Protection Gore NPS Mo. Ma
Occlusion versus Filters Disadvantages v Complete occlusion v Attractive in soft plaque or v Excludes pts with isolated hemispheres or thrombus contralateral severe v Can use any stent stenoses or occlusions system v Larger sheath size v Cross most lesions with v Speed is important wire of choice. Advantages v Complete occlusion
Anectdotally Speaking, I Prefer Proximal Protection for High Risk Stent Patients F Lesion Characteristics v Echolucent “vulnerable” plaque v Heavily calcified lesion v String sign v Visible lesion thrombus
Carotid Stenting: Technique Angiography Access to the common carotid artery Placement of protection device Predilating is Optional Deploying the stent Post-dilating the stent Protection device retrieval and final angiography
Carotid Stenting: Technique Angiography Access to the common carotid artery Placement of protection device Predilating Deploying the stent Post-dilating also optional Protection device retrieval and final angiography
Post Dilitation
Post Angiography
Carotid Stenting: Technique Angiography Access to the common carotid artery Placement of protection device Predilating Deploying the stent Post-dilating the stent Protection device retrieval and final angiography
My Personal Tips. . . Use proximal protection whenever possible. Pre-treat with DAP Rx 24 h before the procedure. Expect hypotension. Pre-dilate with 5 x 20 -30 balloon. Only post-dilate if stent is underexpanded. Continue DAP Rx indefinitely for patients with neck XRT.
Remember…Carotid Stenting is an alternative to CEA, but is not possible in every case due to limitations in the technology. A failure is better than a stroke!
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