2. Mohammad Mahdi Daei Interventional Cardiologist CAROTID ARTERY STENTING

3. MAGNITUDE OF THE PROBLEM 795,000 Americans annually suffer a STROKE 25% die #3 killer of Americans #1 cause of long term disability

4. THREE STROKE TYPES Ischemic Stroke Clot occluding artery 85% Intracerebral Hemorrhage Bleeding into brain 10% Subarachnoid Hemorrhage Bleeding around brain 5% WWW.ACPONLINE.ORG/ABOUT_ACP/CHAPTE RS/OK/GORDON.PPT‎

5. MAJOR CATEGORIES OF ISCHEMIC STROKE Thrombosis Embolism Global-Ischemic or Hypotensive Stroke

6. THROMBOTIC STROKE Atherosclerosis: the commonest pathology of vascular obstruction leading to thrombosis Other pathological causes: Fibro muscular dysplasia Arteritis (Giant Cell & Takayasu) Dissection of vessel wall Hypercoaguability

7. EMBOLIC STROKE Two most common sources of emboli: Left sided cardiac chambers Artery to artery stroke: as in detachment of a thrombus from ICA at the site of a plaque

9. STROKE  80 % of strokes : ischaemic in orgin  20 – 25 % of ischaemic stroke : carotid stenosis  Risk of stroke correlates with severity of carotid stenosis

10. TREATMENT OPTIONS Medical therapy Carotid endarterectomy Carotid artery stenting

11. CEA SUPERIOR TO MEDICAL THERAPY Asymptomatic carotid stenosis  Asymptomatic Carotid Surgery Trial (ACST)  Carotid stenosis >60% : 5 yrs stroke rate reduced from 11.8% to 6.4%  10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1)  10 yrs stroke rate reduced from 17.9% to 13.4%  Asmptomatic Carotid Atherosclerosis Study (ACAS) A. Halliday Lancet 2004 JAMA 1995 A. Halliday Lancet 2010

12. CAROTID ENDARTERECTOMY (CEA)

13. MATCHING PATIENT TO INTERVENTION  Treatment decisions depends on patient-specific factors 1. Risk factors for CEA 2. Risk factors for CAS Medical Surgical / Anatomical

14. RISK FACTORS FOR CEA M edical risk factors  CHF and left ventricular dysfunction  Unstable angina or recent MI (<30 days)  Coronary artery disease (CAD)  Open heart surgery needed within 6 weeks  Severe pulmonary dysfunction

15. RISK FACTORS FOR CEA Surgical / Anatomical risk factors Surgical Factors  Restenosis after prior CEA  Previous ablative neck surgery (e.g. radical neck dissection, laryngectomy)  Previous neck irradiation  Contralateral vocal cord paralysis  Tracheostomy

16. RISK FACTORS FOR CEA S urgical / Anatomical risk factors Anatomical Factors  High carotid bifurcation (above C2)  Extension of athersclerotic lesion into intracranial ICA or proximal CCA below clavicle

17. RISK FACTORS FOR CAS

18. MANAGEMENT ALGORITHM HIGH risk for surgery Favourable anatomy for CAS CASCAS Unfavourable anatomy for CAS CEACEA Symptomatic >= 50% CS LOW risk for surgery Asymptomatic >= 70% CS BMTBMT

19. CONCLUSIONS Carotid endarterectomy has been established as the gold standard for treatment of carotid artery stenosis NASCET and ACAS trials Carotid stenting remains to be proven as a viable alternative to endarterectomy in all patients SAPPHIRE results suggest that CAS is at least equivalent to CEA in high risk patients ICSS results suggest that CAS may cause higher peri-operative morbidity in symptomatic patients CREST results suggest equivalency of CAS to CEA for all patients with carotid stenosis for composite endpoint of death / stroke/ MI However, stroke is more common in CAS, and has a greater impact on quality of life, that MI

21. CAROTID WALLSTENT™ (BSCI) S/E monorail closed cell braided chromium cobalt Diameter -6, 8, 10 mm Length -30, 40, 50 mm 5F -6, 8 mm 6F -10 mm

22. FilterWire EZ™ (BSCI) One size fits 3.5 to 5.5mm vessel diameters 3.2F Profile 0.014’’ Monorail™ exchange system Preloaded wire 110 micron Polyurethane membrane Suspended Radiopaque Nitinol loop Adapts to vessel sizes and diameter changes

23. GUIDANT ACCULINK/ACCUNET S/E OPEN CELL NITINOL WITH LONGITUDINAL LINKS

24. 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) Basic Equipment

25. CAROTID STENT: TARGET LESION LOCATION ICA alone: 3% Bifurcation: 90% CCA alone: 5% Multiple: 2%

26. 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 Fundamental Steps

27. CAROTID STENTING NEED FOR COMPLETE INVENTORY Diagnostic Catheters Vitek Vitek Simmons 1 and 2 Simmons 1 and 2 Headhunter Headhunter Davis Davis Berenstein Berenstein HN2 HN2 Others Others 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

28. Bovine Arch Work-horse Guides

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

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

32. ANY QUESTIONS?