1. CAROTID STENTING: Step-by-Step Technique
Stephen Ramee, MD and Tyrone J. Collins, M.D.
Interventional Cardiology
Ochsner Medical Center
New Orleans, LA

2. Stephen R. Ramee, MD Contracted Research / Grant Support:
Cordis Corporation
Consulting Fees:
AccessClosure, Inc.

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

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

5. 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
x 20-30mm mm balloons
Self-expanding carotid stents

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

7. 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

8. 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

9. Aortic Arch Anatomy

10. Aortic Arch Anatomy

11. 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.

12. Carotid Stenting Technique Aortogram
Pigtail catheter
Digital subtraction
Largest field of view possible

13. Aortic Arch Types
Type I
Type II
Type III

14. Simple Carotid Anatomy

15. Type I - “Simple Aortic Arch”

16. “Difficult Aortic Arch”
Type III
“Difficult Aortic Arch”

17. 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

18. Tool Box: Diagnostic Catheters
4 or 5 Fr catheters
0.035 Hydrophilic wires
Regular & XS

19. 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.

20. Carotid Artery Stenting Catheters for Angiography and Access
Simmons
Berenstein
Judkins Right
Vitek
Amplatz

21. Berenstein

22. Vitek

23. Simmons

24. Carotid Access: Summary

25. 6 Fr. Sheath

26. 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

27. Exchange Technique

28. Exchange Technique

29. Exchange Technique

30. 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

31. Coaxial Technique

32. Coaxial Technique

33. Coaxial Technique

34. Exchange Technique

35. Baseline Angiography

36. Access External Carotid

37. Xtra Stiff Wire Placed in External Carotid

38. Sheath Inserted and Wire Removed

39. 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

40. Wire in the ECA

41. Guide brought over the wire

42. Guiding Catheter at innominate origin

43. 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

44. 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

45. 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 CV Accunet
Fibernet
Antegrade
Flow

46. 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

47. Anectdotally Speaking, I Prefer Proximal Protection for High Risk Stent Patients
Lesion Characteristics
Echolucent “vulnerable” plaque
Heavily calcified lesion
String sign
Visible lesion thrombus

48. 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

49. 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

50. Post Dilitation

51. Post Angiography

52. 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

53. My Personal Tips... Use proximal protection whenever possible.
Pre-treat with DAP Rx 24h before the procedure.
Expect hypotension.
Pre-dilate with 5 x balloon.
Only post-dilate if stent is underexpanded.
Continue DAP Rx indefinitely for patients with neck XRT.

54. 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!