Efficacy of a filter device in the prevention of embolic events during carotid angioplasty and stenting: An ex vivo analysis Takao Ohki, MD, Gary S.

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Presentation transcript:

Efficacy of a filter device in the prevention of embolic events during carotid angioplasty and stenting: An ex vivo analysis Takao Ohki, MD, Gary S. Roubin, MD, Frank J. Veith, MD, Sriram S. Iyer, MD, Eamon Brady, PhD Journal of Vascular Surgery Volume 30, Issue 6, Pages 1034-1044 (December 1999) DOI: 10.1016/S0741-5214(99)70041-8 Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 1 A, Human carotid plaque specimen. Specimens were removed as plaque casts of carotid bifurcation and were kept circumferentially intact. i, Internal carotid artery; e, external carotid artery; c, common carotid artery; s, superior thyroid artery. B, Expanded polytetrafluoroethylene (ePTFE) wrapped specimen. Distal half of ePTFE graft is cut longitudinally, and plaque is inserted into graft. Redundant ePTFE material covering internal carotid plaque portion is trimmed and sutured (s) . With permission from Ohki T, Marin ML, Lyon RT, Berdejo GL, Ohki M, Soundararajan K, et al. Human ex vivo carotid artery bifurcation stenting: correlation of lesion characteristics with embolic potential. J Vasc Surg 1998;27:463-71. Journal of Vascular Surgery 1999 30, 1034-1044DOI: (10.1016/S0741-5214(99)70041-8) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 2 Schematic drawing of ex vivo apparatus and bath. Expanded polytetrafluoroethylene covered plaque (CP) is connected to custom-made sheath. This plaque-sheath complex is connected to main port of bath. Saline solution bag raised to 130 cm above the bath is connected to flush channel of main port to maintain continuous flow through lumen of specimen (arrows) . Sheath with three-way valve at proximal end is inserted into center channel of main port, which allows insertion of various endovascular imaging and interventional devices. Effluent is drained through a filter to collect embolic particles generated during endovascular procedure. Orifice of external carotid artery (ECA) is ligated to maintain closed circuit. Journal of Vascular Surgery 1999 30, 1034-1044DOI: (10.1016/S0741-5214(99)70041-8) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 3 A, Preinterventional ex vivo angiogram. High-grade stenosis is seen in internal carotid artery. External carotid artery (e) is ligated. r, Radiopaque ruler. B, Initial filter guidewire passage through stenosis was accomplished without difficulty, owing to low profile and smooth transition between tip wire and delivery catheter. f, Nitinol-supported filter encased in delivery catheter before deployment. C, Fluoroscopic image after filter guidewire deployment. Nitinol-supported filter (f) is fully deployed in distal internal carotid artery. D, Predilatation of lesion is performed with a coronary balloon under filter protection. E, Wallstent is also deployed under filter protection. F, Completion angiogram shows successful recanalization of internal carotid artery. Flow through filter is preserved. a, Air emboli captured in filter. Journal of Vascular Surgery 1999 30, 1034-1044DOI: (10.1016/S0741-5214(99)70041-8) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 4 Drawing of MedNova NeuroShield (Horsham, W Sussex, United Kingdom). Filter guidewire is initially encased in low-profile delivery catheter (d) . After delivery catheter retrieval, filter (f) is completely deployed. w, 0.014-in shapeable guidewire; b, bullet providing smooth transition between wire and delivery catheter. Journal of Vascular Surgery 1999 30, 1034-1044DOI: (10.1016/S0741-5214(99)70041-8) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 5 MedNova NeuroShield (Horsham, W Sussex, United Kingdom). Filtration element has large entry ports at proximal end and multiple perfusion ports (p) at distal end. Filtration element contains pre-shaped nitinol (n) expansion system that assists in filter deployment and in visualization under fluoroscopy. e, Embolic particles. Journal of Vascular Surgery 1999 30, 1034-1044DOI: (10.1016/S0741-5214(99)70041-8) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 6 Microscopic view of embolic particles released during initial filter guidewire passage. Three small particles consisting of atherosclerotic debris were recovered (filter size, 130 μm; original magnification, × 40). Journal of Vascular Surgery 1999 30, 1034-1044DOI: (10.1016/S0741-5214(99)70041-8) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 7 A, Close-up view of inside of filter guidewire after carotid artery stenting. Multiple embolic particles have been captured in filter. n, Nitinol frame. B, Microscopic view of embolic particles captured by filter guidewire. These particles consisted of organized thrombus and atheroscrelotic debris (filter size, 130 m; original magnification, × 40). Journal of Vascular Surgery 1999 30, 1034-1044DOI: (10.1016/S0741-5214(99)70041-8) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 8 Microscopic view of embolic particles that were missed by filter guidewire. Journal of Vascular Surgery 1999 30, 1034-1044DOI: (10.1016/S0741-5214(99)70041-8) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 9 Size and number of embolic particles released during initial filter passage, those captured by filter, and those missed by filter. Journal of Vascular Surgery 1999 30, 1034-1044DOI: (10.1016/S0741-5214(99)70041-8) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions