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Should We Be Doing This? Brains: Carotid Stenting

Should We Be Doing This? Brains: Carotid Stenting. Keith G Oldroyd Department of Cardiology Western Infirmary. Carotid Intervention. CEA results Symptomatic Asymptomatic CAS + DP registries CEA vs CAS in RCT’s Setting up a CAS service MY WORST COMPLICATION!!. NASCET/ECST/VA309.

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Should We Be Doing This? Brains: Carotid Stenting

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  1. Should We Be Doing This?Brains: Carotid Stenting Keith G Oldroyd Department of Cardiology Western Infirmary

  2. Carotid Intervention • CEA results • Symptomatic • Asymptomatic • CAS + DP registries • CEA vs CAS in RCT’s • Setting up a CAS service • MY WORST COMPLICATION!!

  3. NASCET/ECST/VA309 • 6092 patients with > 35K patients years Sub-totals – trend towards benefit at 2 years, gone by 5 years Amaurosis fugax only – no benefit Absolute benefit increases with age Lancet Jan 11, 2003

  4. NASCET

  5. CEA rate/100,000 in Scotland by Health Board Stroke rate = 200 per 100K 80% ischaemic = 160 50% carotid stenosis = 80

  6. CEA Rate / million >40 yrs old

  7. MRC Asymptomatic Carotid Surgery Trial (ACST)

  8. CAROTID STENTING

  9. CAROTID STENTING

  10. CAROTID STENTING

  11. WALLSTENT

  12. The GuardWire Protection System

  13. CAFE-USA RegistryPercusurge in Carotid Stenting • 212 patients • 99% procedural success • 8% required “staged” protection • Visual embolic material in every case • Mean 12 min of balloon occlusion • 30 day - mortality: 1.4% stroke: 2.4%

  14. CAFE-USA RegistryTCD Sub-study

  15. Carotid Wallstent™ (BSCI) • S/E monorail closed cell • braided chromium cobalt • Diameter - 6, 8, 10 mm • Length - 30, 40, 50 mm • 5F - 6, 8 mm • 6F - 10 mm

  16. FilterWire EZ™ (BSCI) • One size fits 3.5 to 5.5mm vessel diameters • 3.2F Profile • 0.014’’ Monorail™ exchange system • Preloaded wire 110 micron Polyurethane membrane • Suspended Radiopaque Nitinol loop • Adapts to vessel sizes and diameter changes

  17. Guidant Acculink/AccunetS/E open cell nitinol with longitudinal links

  18. Protégé GPS (eV3)S/E open cell nitinol carotid stent

  19. SpideRX™ • Heparin coated nitinol braid filter • Multiple sizes from 3-7mm to match vessel size • Use any 014” guidewire for initial cross • Single Dual-Ended Low-Profile Catheter • Pre-loaded Filter • 6Fr compatible • Rapid exchange • Snapwire converts to 190 cm RX length

  20. NexStent™ (EndoTex/BSCI) • 30mm S/E closed cell rolled nitinol sheet • 5F system that can deliver a 9mm stent • Straight and tapered vessel segments of 4-9mm • High crush resistance • Moderate chronic outward radial force

  21. NexStent™ • Integrated deployment handle allows accurate stent placement by providing a mechanical advantage during retraction of delivery sheath • Distal flare anchors stent during deployment with minimal foreshortening of < 10% at 9mm

  22. USA Carotid Stenting Studies30-Day Composite Endpoint 7.8% 7.2% 5.8% 5.8% 5.2% Patients (%) 3.8% MAVErIC N=52 CABERNET N=454 BEACH N=747 ARCHeR2 N=278 SAPPHIRE SECuRITY N=305

  23. CAVATAS - 1

  24. Stenting and Angioplasty with Protection in Patients at High Risk for EndarterectomySAPPHIRE • RCT using distal protection in stent group • 29 US centres • Asymptomatic ≥ 80% • Symptomatic ≥ 50% • At least 1 high risk feature (defined by surgeons) • Age > 80 • CHF • Severe COPD • Previous CEA • Previous radiation therapy or neck surgery • Proximal or distal lesions • (contralateral occlusion)

  25. SAPPHIREStenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy • Cases assessed by interventionist, surgeon and neurologist • Consensus: randomised • Rejected for CEA: intervention registry • Rejected for CAS: surgical registry • Enrollment stopped prematurely in June 2002 • Stent registry: 409 • Surgical registry: 7 • Randomised: 310

  26. S/E open cell nitinol Smart/PreciseTM stent and Angioguard XPTM distal protection system

  27. SAPPHIRE30 day complications

  28. SAPPHIRE12 month outcomes NEJM 2004; 351: 493-501

  29. ELOCAS Registry • M Bosiers, Dendermonde, Belgium • P Peeters, Imelda Hospital, Belgium • H Sievert, Frankfurt CC, Germany • A Cremonesi, Ravenna, Italy • Feb 93 to Dec 04 • 2172 patients J Cardiovasc Surgery 2005; 46: 241-247

  30. ELOCAS Registry

  31. Starting a CAS Service • Team approach • Vascular surgeons • Stroke physician/neurologist • Interventional radiologist/cardiologist • High quality readily available imaging • Doppler U/S and TCD • MRA • HDU/CCU care post procedure • Meticulous control of BP

  32. My Worst Complication • 75 year old male • 3 minor left sided anterior circulation strokes in previous 5 months and hospitalised since first event • CHD – previous MI • Chronic Cl.diff infection • Chronic alcohol abuse • CT brain – diffuse ischaemic change/moderate atrophy • Doppler U/S • > 70% RICA stenosis; 50-69% LICA • MRA – confirmed severe RICA stenosis with ulceration • Turned down for CEA • Referred for CAS

  33. JB – RCCA access

  34. JB – RICA stenosis

  35. JB – Stent deployment (Protégé)

  36. JB – post Protégé

  37. JB – Stent deployment (Wallstent)

  38. JB – Final result

  39. JB – Post CAS • Uneventful recovery up to 5 days post CAS • Sudden deterioration with hypertension and focal seizures • Deteriorating conscious level • Doppler U/S – widely patent stents but very high flow velocities in ICA and MCA • CT – diffuse basal SAH • Died 36 hours post CT • Diagnosis – ?

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