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: AccessClosure, Inc.

Stephen R. Ramee, MD Ownership Interest (Stocks, Stock Options, or other Ownership Interest): SquareOne I-Therapeutics Corporation Hot Spur Lazarus Effect Honoraria: Sadra Medical

Ochsner Carotid Stent Team Tyrone Ramee Ken White Chip Gabby Laurie Ochsner Heart & Vascular Institute

Carotid Stent Equipment 6 Fr. or larger 90cm 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 20-30mm 0.014 mm balloons Self-expanding carotid stents

Dual-Plane Lab Digital angiography Digital subtraction Roadmapping Archival storage Dual inch image intensifiers One digital unit Dedicated slave monitor

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 I Type II Type III

Simple Carotid Anatomy

Type I - “Simple Aortic Arch”

“Difficult 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 4 or 5 Fr catheters 0.035 Hydrophilic wires Regular & 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 vertebro-basilar 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 4-5Fr. 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 5Fr. Catheter (125cm) through sheath/guide to engage CCA or Innominate Artery .035” Extra stiff angled glidewire to distal Carotid artery Advance 5Fr. Catheter to ECA Exchange for .035” Amplatz XS wire Advance sheath/guide coaxially over 5Fr. 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 8Fr 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 Endovascular Clamping by CCA and ECA Balloon Occlusion Gore NPS Mo.Ma Proximal Protection Flow Blockage by distal ICA Occlusion PercuSurge GuardWire Distal Flow Blockage Distal ICA Filtering AngioGuard EmboShield EPI FilterWire Spider CV3 Accunet Fibernet Antegrade Flow

Occlusion versus Filters Advantages Complete occlusion Attractive in soft plaque or thrombus Can use any stent system Cross most lesions with wire of choice. Disadvantages Complete occlusion Excludes pts with isolated hemispheres or contralateral severe stenoses or occlusions Larger sheath size Speed is important

Anectdotally Speaking, I Prefer Proximal Protection for High Risk Stent Patients Lesion Characteristics Echolucent “vulnerable” plaque Heavily calcified lesion String sign 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 24h 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!