1. Carotid Stent Techniques Michael J. Cowley, M.D. FSCAI

2. Carotid Stent Technique Angiography (pigtail, access catheter) Stiff hydrophilic guide wire (0.035”) Long interventional sheath or guide catheter Embolic protection device Appropriate size balloon catheter Self-expanding (FDA approved) carotid stent Closure device (optional) Angiography (pigtail, access catheter) Stiff hydrophilic guide wire (0.035”) Long interventional sheath or guide catheter Embolic protection device Appropriate size balloon catheter Self-expanding (FDA approved) carotid stent Closure device (optional) Basic Equipment

3. Carotid Stent: Target Lesion Location ICA alone: 3% Bifurcation: 90% CCA alone: 5% Multiple: 2%

4. Carotid Stent Technique Femoral access Arch angiography Selective catheterization of target CCA Wire placement in ECA Sheath or GC placement in distal CCA Placement of embolic protection device Pre-dilation of lesion Stent placement Post-dilation of stent Removal of EPD Final angiography Femoral access Arch angiography Selective catheterization of target CCA Wire placement in ECA Sheath or GC placement in distal CCA Placement of embolic protection device Pre-dilation of lesion Stent placement Post-dilation of stent Removal of EPD Final angiography Fundamental Steps

5. Carotid Stenting Need for complete inventory Diagnostic Catheters VitekVitek Simmons 1 and 2Simmons 1 and 2 HeadhunterHeadhunter DavisDavis BerensteinBerenstein HN2HN2 OthersOthers Diagnostic Catheters VitekVitek Simmons 1 and 2Simmons 1 and 2 HeadhunterHeadhunter DavisDavis BerensteinBerenstein HN2HN2 OthersOthers Guidewires 0.035” exchange glidewire0.035” exchange glidewire 0.038” exchange glidewire0.038” exchange glidewire 0.035” Amplatz SS (1cm vs 4cm floppy)0.035” Amplatz SS (1cm vs 4cm floppy) Wholey exchangeWholey exchange 0.035” Rosen0.035” Rosen 0.014 Spartacore0.014 Spartacore SV 14/5SV 14/5 0.018” Roadrunner0.018” Roadrunner

6. Bovine Arch Work-horse Guides

7. Simple Curved Catheters IMA Modified AR1 JR 4 ‘Coronary catheters’ Consider using dedicated catheters!!! Consider using dedicated catheters!!!

8. Complex Curved Catheters Simmons 1, 2, and 3 curves VTK

9. Wires Selections: Soft, Stiff, and Variable Diameters Wires Selections: Soft, Stiff, and Variable Diameters - 0.035” Rosen wire - 0.035” hydrophilic wire - Straight extra-stiff 300 cm Amplatz wire - TAD wire (0.018”- 0.035”) w/ DOC - 0.038” extra-stiff Glide- wire ideal for VTK catheter - 280 cm Magic Torque - 0.014” buddy wires (Sparta-Core, BMW)

10. Access Strategy Arch Anatomy Common carotid anatomy Anatomy of the lesion Patency of external carotid artery Anatomy of internal carotid distal to the lesion Arch Anatomy Common carotid anatomy Anatomy of the lesion Patency of external carotid artery Anatomy of internal carotid distal to the lesion Determined by:

11. Arch Aortogram 30-40 LAO view Field of view should include origin of great vessels and extend to include the carotid bifurcation Patient’s head should be straight with chin turned upward 30-40 LAO view Field of view should include origin of great vessels and extend to include the carotid bifurcation Patient’s head should be straight with chin turned upward

12. Carotid Angiography Ipsilateral oblique and lateral views (additional views may be necessary) Contralateral carotid (Circle of Willis, collaterals, etc) 5 or 6 F with appropriate curve Intracranial angiography also important Ipsilateral oblique and lateral views (additional views may be necessary) Contralateral carotid (Circle of Willis, collaterals, etc) 5 or 6 F with appropriate curve Intracranial angiography also important

13. Carotid Angiography Site of stenosis Bifurcation involvement Landing zone for EPD Patency of ECA Presence of ICA tortuosity Presence of ulceration Severity of stenosis Lesion length Degree of calcification Presence of thrombus Key features

14. Intracerebral Angiography Anterior cerebral circulation viewed by PA cranial (15-20 degrees) and lateral views Important to visualize both arterial and venous phases: - Intracerebral disease - Collateral circulation - Presence of AVM, aneurysm, isolated hemisphere - Missing arterial phase vessels (allows identification of embolization post CAS) Anterior cerebral circulation viewed by PA cranial (15-20 degrees) and lateral views Important to visualize both arterial and venous phases: - Intracerebral disease - Collateral circulation - Presence of AVM, aneurysm, isolated hemisphere - Missing arterial phase vessels (allows identification of embolization post CAS)

15. Carotid Stent Technique Dx catheter engages innominate and road map of carotid bifurcation done Stiff angled 0.035’ guide wire advanced into distal CCA or ECA under roadmap guidance Diagnostic catheter exchanged for guide catheter Guidewire removed Dx catheter engages innominate and road map of carotid bifurcation done Stiff angled 0.035’ guide wire advanced into distal CCA or ECA under roadmap guidance Diagnostic catheter exchanged for guide catheter Guidewire removed Guide Catheter Placement

16. Carotid Stent Technique Long (125 cm) diagnostic catheter telescoped through 8F GC Roadmap view (preferably lateral) to visualize bifurcation of ECA and ICA Stiff, angled 0.035 hydrophilic wire advanced into ECA using roadmap guidance Dx catheter advanced over wire into distal CCA GC advanced over wire/Dx catheter into distal CCA Diagnostic catheter and wire removed Long (125 cm) diagnostic catheter telescoped through 8F GC Roadmap view (preferably lateral) to visualize bifurcation of ECA and ICA Stiff, angled 0.035 hydrophilic wire advanced into ECA using roadmap guidance Dx catheter advanced over wire into distal CCA GC advanced over wire/Dx catheter into distal CCA Diagnostic catheter and wire removed Guide Catheter Placement

17. Carotid Stent Technique Diagnostic catheter (125 cm) engaged in innominate or LCCA Roadmap view (preferably lateral) to visualize bifurcation of ECA and ICA Stiff, angled 0.035 hydrophilic wire advanced into ECA using roadmap guidance Dx catheter advanced over wire into the ECA Guide wire exchanged for super stiff (1 or 6 cm soft tip) 6F sheath advanced into CCA over guidewire Guidewire removed Diagnostic catheter (125 cm) engaged in innominate or LCCA Roadmap view (preferably lateral) to visualize bifurcation of ECA and ICA Stiff, angled 0.035 hydrophilic wire advanced into ECA using roadmap guidance Dx catheter advanced over wire into the ECA Guide wire exchanged for super stiff (1 or 6 cm soft tip) 6F sheath advanced into CCA over guidewire Guidewire removed Sheath Placement in CCA

18. Carotid Stent Technique Better torque control More rigid; better support Better for tortuousity Many pre-formed curves available to fit anatomy Better torque control More rigid; better support Better for tortuousity Many pre-formed curves available to fit anatomy 8 Fr sheath size Uneven transition with inner catheter Advantages Disadvantages Guide Catheters

19. Carotid Stent Technique 6 Fr sheath size Integrated dilator provides smooth transition 6 Fr sheath size Integrated dilator provides smooth transition No torque control Less rigid; less support Less favorable for tortuous anatomy More likely to slip back during EPD or stent delivery Advantages Disadvantages Long Sheath System

20. Carotid Stent Technique Working View

21. Carotid Stent Technique AngioGuard XP 100 µ pore size Filter Wire EX 80-110 µ pore size ACCUNET ≤150 µ pore size Distal Protection Devices

22. Filters: Newer Devices FilterWire EZ SPIDER Rubicon Interceptor Emboshield

23. Carotid Stent Technique Advance EPD across lesion and filter in distal ICA in straight segment belong siphon Buddy wire may guide catheter with angled tip may be needed if angulation and tortuousity present Percusurge is option if difficult passage for filter device Advance EPD across lesion and filter in distal ICA in straight segment belong siphon Buddy wire may guide catheter with angled tip may be needed if angulation and tortuousity present Percusurge is option if difficult passage for filter device Distal Protection Placement

24. Carotid Stent Technique Preferable to assure stent delivery and adequate stent expansion May provide information on hemodynamic response to carotid sinus stimulation Helpful for assessment of lesion length and reference vessel diameter PTCA balloon 4mm x 20-40 mm long Brief inflation to eliminate indentation Slow deflation may reduce embolization Preferable to assure stent delivery and adequate stent expansion May provide information on hemodynamic response to carotid sinus stimulation Helpful for assessment of lesion length and reference vessel diameter PTCA balloon 4mm x 20-40 mm long Brief inflation to eliminate indentation Slow deflation may reduce embolization Pre-dilation

25. Carotid Stent Technique Flush central lumen and lock stent connector Advance stent delivery system over EPD shaft past lesion site (do not advance against resistance) Position stent in lesion by pulling back SDS until radio-opaque shaft markers are proximal and distal to the lesion Positioning facilitated by use of bony landmarks, roadmap image, and contrast injection Deploy according to IFU for particular stent Flush central lumen and lock stent connector Advance stent delivery system over EPD shaft past lesion site (do not advance against resistance) Position stent in lesion by pulling back SDS until radio-opaque shaft markers are proximal and distal to the lesion Positioning facilitated by use of bony landmarks, roadmap image, and contrast injection Deploy according to IFU for particular stent Stent Placement

26. Selection of Carotid Stent Stent diameter Tapering vs non-tapering vessel Oversize largest “target” by 1-2mm Stent length Cover “shoulder-to-shoulder” Avoid stent edge in bends When in doubt, use longer stent Stent diameter Tapering vs non-tapering vessel Oversize largest “target” by 1-2mm Stent length Cover “shoulder-to-shoulder” Avoid stent edge in bends When in doubt, use longer stent

27. Carotid Stent Technique Post dilate to achieve adequate lumen (5 mm or 6 mm balloon) Assess final result and distal flow Remove EPD if satisfactory flow If slow flow, determine cause spasm, dissection, full filter Aspiration with export catheter or Pronto catheter before removal if filter full Post dilate to achieve adequate lumen (5 mm or 6 mm balloon) Assess final result and distal flow Remove EPD if satisfactory flow If slow flow, determine cause spasm, dissection, full filter Aspiration with export catheter or Pronto catheter before removal if filter full

28. Carotid Stent Technique Carotid Angiography: - evaluate target lesion status - stent expansion - distal runoff - evidence of spasm or dissection PA and lateral intracranial views - exclude evidence of embolization Carotid Angiography: - evaluate target lesion status - stent expansion - distal runoff - evidence of spasm or dissection PA and lateral intracranial views - exclude evidence of embolization Final Angiography

29. Carotid Stenting Intraprocedural Medications to Have Available Anti-thrombotics / lytics Heparin IIb/IIIa inhibitors Retavase, tPA, Urokinase Anti-thrombotics / lytics Heparin IIb/IIIa inhibitors Retavase, tPA, Urokinase Pressors Neosynephrine drip Levophed drip AramineVasodilatorsNTGNiprideAnticholinergicsAtropine

30. Carotid Stent Techniques Don’t force!!!…if not advancing easily select another shape or rethink your treatment options Don’t start CAS with suboptimal support… like coronary work, the time to find out you can’t do it is not in the middle of the case (especially with distal protection) Don’t force!!!…if not advancing easily select another shape or rethink your treatment options Don’t start CAS with suboptimal support… like coronary work, the time to find out you can’t do it is not in the middle of the case (especially with distal protection) General Guidelines

31. Carotid Access Issues Complications dependent on: - Symptomatic vs asymptomatic status - Duration of catheter in cerebral arteries - Number of catheter exchanges - Number of vessels cannulated - Contrast volume, fluoro time At present appropriately patients for CAS are all “high risk” for anatomic or clinical reasons Target high risk clinical with low risk anatomic features in your initial experience Complications dependent on: - Symptomatic vs asymptomatic status - Duration of catheter in cerebral arteries - Number of catheter exchanges - Number of vessels cannulated - Contrast volume, fluoro time At present appropriately patients for CAS are all “high risk” for anatomic or clinical reasons Target high risk clinical with low risk anatomic features in your initial experience Largely determined by case selection

34. 6.5 F Slip-Cath ® 6F Shuttle Sheath Shuttle Select™ System H1, JB 1.085” OD 125 cm

35. Bovine Arch Work-horse Guides

36. 8F Guiding Catheter & 120 cm 6F Diagnostic Catheter VS. Shuttle Select™ System

37. Arch Aortogram: A ‘Dry Run’ for Carotid Stenting Evaluate: - Access site, iliacs - Arch configuration and appropriate catheter/wire combinations for arch cannulation - Assess possible sheath placement challenges - Best angles to highlight carotid bifurcation, DP landing zone, etc.

38. Carotid Access Issues Complications dependent on: - Symptomatic vs asymptomatic status - Duration of catheter in cerebral arteries - Number of catheter exchanges - Number of vessels cannulated - Contrast volume, fluoro time At present appropriately patients for CAS are all “high risk” for anatomic or clinical reasons Complications dependent on: - Symptomatic vs asymptomatic status - Duration of catheter in cerebral arteries - Number of catheter exchanges - Number of vessels cannulated - Contrast volume, fluoro time At present appropriately patients for CAS are all “high risk” for anatomic or clinical reasons