2. Manageing and Avoiding Complications in CAS
LN Hopkins, MD
A Siddiqui, MD,PhD
E Levy MD,

3. L. Nelson Hopkins, MD DISCLOSURES Consulting Fees
Abbott Vascular, Bard Peripheral Vascular, Boston Scientific Corporation, Micrus Endovascular Cordis, a Johnson & Johnson company
Grants/Contracted Research
Cordis, a Johnson & Johnson company, Boston Scientific Corporation, Micrus Endovascular
Honoraria
AccessClosure, Inc., Bard Peripheral Vascular, Boston Scientific Corporation, Cordis, a Johnson & Johnson company, marketRx, Inc., Micrus Endovascular, Medsn
Ownership Interest (Stocks, Stock Options or Other Ownership Interest)
APW Holding, Inc., Boston Scientific Corporation, Magellan Spine Tech, Inc., MedFocus Accelerator Fund, Micrus Endovascular

4. Staying Out Of Trouble CAS 2006
Know the data
Don’t stent high risk CAS pts… CEA is a great operation
Quit before you hurt someone
It’s all about Judgment!

5. Complication Avoidance/Mgmt
Patient selection
Perioperative mgmt
-pharmacologic,BP,Fluids
Technique
Tips ‘n tricks
Embolic protection

6. Is CAS Really Indicated??
1) High risk for CEA 2) Sx and > 70% 3) Asx and > 75% 4) 5 yr life expectancy 5) Trial candidate

7. Whom To Avoid…2010 Beyond…??? Lesion Characteristics
- long, irregular stenosis
- severe tortuosity perilesional
- pseudoocclusion
- string sign
- luminal thrombus

8. CAS: Whom to Avoid? Difficult Access
Calcified, tortuous Aortic Arch
Tortuous, diseased, kinked CCA
Severe Iliac disease

9. CAS: Whom to Avoid?
Neurologic instability - recent large infarct - crescendo TIA - stroke in evolution

10. Complication Avoidance
Patient selection
Perioperative mgmt
-pharmacologic,BP,Fluids
Technique
Tips ‘n tricks
Embolic protection

11. Pseudospasm Resolves When Wires etc Removed
1st stent placed. Distal, just caught the lesion, spasm associated with end of stent

12. What is this??

13. And this??
What To Do???...
Wallstent

14. Post-op Hypotension Carotid Sinus Reflex Blood Loss (Access Site)
Allergic (anaphylactic) Reaction

15. “Hyperperfusion” Syndrome Hemmorhage Post CAS
Use Embolic Protection
Avoid IIB IIIA Platelet Inhibitors
Avoid Hypertension
Reverse Heparin

16. Pitfalls

17. Interesting Case 62 yo male with TIA (R HP) RTU 70-89% L ICA Stenosis
Uneventful CEA
3 mo later…another TIA!!
Repeat RTU Normal L ICA
Now what to do?

18. Carotid stenosis does not always warrant treatment

19. TIA Differential Diagnosis
Focal ischemia
Seizure
Migraine
Brain tumor
Etc.
Always get CT or MRI Brain!!

20. Neurovascular Rescue Be Prepared…
Microcath & Wires
Clot Retrievers,Balloons
Stents
Thrombolytics
Antiplatelete Agents

21. Cerebral Ischemia How to Recognize
Sudden change in neuro status
Subtle change in neuro status
Change in vital signs
Angiographic changes

22. Cerebral Ischemia What to Do
Finish current maneuver
(Re)establish flow
Neuro evaluation
Cerebral angio - compare to baseline

23. Embolization During CAS Imaging Changes
Angiography… PRE & POST Ischemia
No change
Focal embolus/emboli
Focal or general slowing
Capillary phase

24. This image suggests MCA branch Occlusion
Capillary Phase
Gogos
Pre Stent Post Stent
This image suggests MCA branch Occlusion

25. Tools for Flow Restoration: Microcatheters, Lytics, IIBIIIA
Penumbra
Self Expanding Stent
Wingspan
MERCI

26. Cerebral Embolism Large branch occlusion -lyse / retrieve / stent clot
Small vessels occluded -IIB IIIA platelet blockade

27. Stroke is Evolutionary
Small embolus - initially ‘silent’
May evolve into significant stoke
Don’t ignore “asymptomatic” post op filling defects on angiogram