Overcoming Challenging Anatomy Such as Bad Arches Kinks

Overcoming Challenging Anatomy: Such as Bad Arches, Kinks, Occluded Externals and String Signs Michael Wholey, MD MBA Interventional Radiology Audie Murphy VA Hospital 8: 30 AM Tues Diplomat Room

Financial Obligations • Nothing related to this subject Good Morning. Thank you for coming.

Overcoming Challenging Anatomy: q. Bad Arches q. Kinks q. Occluded Externals q. String Signs

Beware of problems of the aortic arch • Tortuosity, sharp angles • Plaque along the arch • Plaque at orgins of the targeted vessels Hint: Take Advantage of Previous Imaging…CTA or MRA

Importance of the Aorta Arch Angiogram

Uncomplicated Transfemoral Carotid Access 1. 2. 3. 4. 5. 6. Thoracic Angiogram: LAO View Advance Berenstein over wire to engage Inominate Artery. Remove Wire slowly. Small contrast injection to differentiate Subclavian from Right Common Carotid. -May need RAO View Advance wire gently to mid common (avoid wire in ICA) Coaxially advance catheter to proximal/mid CCA Follow Telescope fashion with 6 -7 fr Cook Shuttle Sheath

Diagnostic Catheters for Selecting Aortic Arch • 4 -5 Fr Simple Curve Vertebral, Kumpe, Berenstein, Multipurpose • Mfg: Angiodynamics, Cook, Cordis, Terumo • Secondary Bends JB 1 Headhunter 1 Hockey Stick Cordis SRC

Equipment • • Cook 6 Fr Shuttle Select Carotid Sheath 90 cm with Headhunter 6. 5 Fr TELESCOPE TECHNIQUE Remove Pigtail over the Wholey Wire Exchange 6 Fr Sheath for the Cook Shuttle Sheath Select left common carotid Angio Advance Wholey to edge of stenosis Advance 6. 5 Headhunter Telescope the Cook Sheath Covidien 0. 35” Wholey Wire Remember the Drugs: -Plavix, ASA, Statins before -Heparin or Angiomed during case -Treat BP/HR during case -Plavix and ASA after Sizes: 7, 8, 9, 10 diameter 20, 30, 40 mm length Straight/Tapered

PROBLEMS of the Aortic Arch Complexities of the aortic are responsible for almost all technical failures Ideal Trouble More Trouble

Octogenarian Type 3 Arch Embolic source vulnerable plaque

Basics of Arch Angiogram n From arch angiogram, decide which catheter used to select the Great Vessels – Even if simple arch, look for disease – Is the common carotid involved with severe disease? Is it worth selecting? Crossing the lesion Crossing the aortic arch

AVOID: Shower Emboli DWI Embolic stroke from atherosclerotic arch following carotid intervention Choice Trial had 18% contra lateral strokes

Variations in Arch Anatomy Bovine arch is the most common variant of the aortic: the brachiocephalic (innominate art. shares a common origin with the left common carotid • A bovine arch is apparent in ~15% (range 8 -25%) of the population and is more common in individuals of African descent. Variant origin of the vertebral artery (2. 5 -6% of cases)

Complex Aortic Arches Simple Rules: 1. Decide which catheter will work 2. Do not manipulate excessively in the aortic arch 3. Do Not Cause a Stroke ! Other Tips: -Bovine Anatomy: --Gently advance catheter into innominate and pull back to engage Left CCA, Advance wire, then catheter --Secondary catheter: Simmons 1, carefully back into origin, Simmons 2 if needed.

Aortic Arch: Beware of Forming the Simmons II, III Simmons Reform Rotate • If need to use Simmons II, III, then use the contralateral iliac or if need be, left subclavian

Complex Aortic Arches • Tricks: – May need to change catheters once 0. 035” guidewire in place, switch to 4 fr Glide Cath – For Right Carotid Access: • First gain access into the right subclavian first for support, then gently pull back and engage • Consider right radial/brachial access

Basics: What to do with the Common Carotid? Be careful of diseased common carotids – Stay small and soft (4 Fr, Glidecath) – Avoid going in far, inject from origin – Hand held injection

TIP: Complicated Aortic Arch How will you get access ? I. Telescope with Sheath: Sheath Use Cook Shuttle Select with Vitek and 0. 035” glide to gain access into ECA II. Traditional: Traditional Use diagnostic catheter (i. e. Simmons 2) to gain access with 0. 035” glide into the ECA, then advance glidecath for exchange to Amplatz to allow sheath to be advanced III. Telescope Guide: Guide Use a 8 Fr guide at origin of inomminate, then advance multiple wires to ECA to allow for guide catheter advancement

How to gain support to advance guide? CONCEPT OF MULTIPLE GUIDEWIRES (Placed in ECA) Golden Gate Bridge-made of a series of cables

Guide in position in CCA -With the multiple wires, anatomy shifted slightly, able to advance guide catheter into position in the CCA; -Know where the bifurcation is

Overcoming Challenging Anatomy: q. Bad Arches q. Kinks q. Occluded Externals q. String Signs

Beware of Kinking Target Left ICA but tortuous takeoff proximally 5 Fr Glide catheter

Overcoming Challenging Anatomy: q. Bad Arches q. Kinks q. Occluded Externals q. String Signs

Occluded ECA/Common Carotid Lesion

Overcoming Challenging Anatomy: q. Bad Arches q. Kinks q. Occluded Externals q. String Signs

Make sure a Carotid “string sign” is not an occlusion 2 weeks later

String Sign Case • • Male patient s/p CEA bilateral last year. 6 mos ago had stroke effecting right brain. Previous CTA showed high grade Right CEA re-stenosis. Question string sign. Hypoplastic/absent left vert distal with collateral branches to the left ECA Absent COW posterior communication. Limited Right A 1 segment noted

String Sign Treatment

Conclusion Bad Arches, Kinks, Occluded Externals, String Signs? Be very careful in today’s environment Stay simple with minimal risk But if you do have to get access for CAS or for stroke, tips discussed included using varying diagnostic catheters to get into to switch for stiffer 0. 035” wire, then allowing 6 -7 Fr Cook Shuttle Sheath into the Common Carotid