The document discusses carotid artery disease and treatment options such as carotid angioplasty and stenting. It notes that stroke is a major cause of death and disability in the US. Carotid artery stenosis over 75% poses a high risk of stroke without treatment. Newer techniques like carotid stenting aim to achieve low stroke/death rates of less than 6% for symptomatic patients and 3% for asymptomatic patients. Success requires choosing the right tools, techniques, and protection devices tailored to each patient's anatomy and plaque characteristics. Ongoing studies evaluate newer neuroprotection systems to further reduce embolic risks of carotid stenting.

1. • Carotid angioplasty ,indications ,techniques
And
controversies.
dr gopi krishna.

2. IMPORTANCE
OF
CAROTID ARTERY
DISEASE
TREATMENT

3. Stroke:
• 3rd cause of death in US
• 500,000 cases/year
• 2 milion/year handicaped people
HIGH SOCIAL / ECONOMIC COST
Mellière et al. J Mal Vasc, 1993

4. • 20 - 30% of CVE are related to
carotid occlusive disease.
• Increased incidence with age .
(33% < 45 yrs and 80% >50 yrs)
De Bakey et al. J Endovasc Surg, 1996

5. • Stenoses > 75%
risk of stroke in 1st yr = 2-5%
Roederer et al. Stroke, 1984
Hennereci et al. Brain, 1987
• Ulceration = Iminent stroke
risk of stroke = 7,5%
Autret et al. Lancet, 1987

6. • Carotid stenosis + TIA
• Risk of stroke in 1st yr = 12-13%
5th yr = 30-37%
Sundt et al., 1987
Dennis et al. Stroke, 1990
• CVA - risk in 1st yr = 59%
5th yr = 25-45%
Sacco et al. Stroke, 1982
Meissner et al. Stroke, 1988

7. • Heterogeneous and ulcerated
lesions = Risk 2-4 x
Langsfeld et al. J Vasc Surg, 1989
Sterpetti et al. Stroke, 1988

8. SURGICAL
TREATMENT

9. ENDARTERECTOMY (1953)
– risk of stroke
–TIA = 1-2% / Yr
–CVA = 2-3% / Yr

11. Carotid Stent
AHA Quality Standards
Surgical Treatment
CVA / Death
• Symptomatic Patients < 6%
• Asymptomatic Patients < 3%

12. Carotid Stent
NASCET (North American Syntomatic Carotid Trial)
 Cranial
Nerve Lesion : 7,6%
 Hematoma : 5,5%
Extensive list of exclusion criteria !
N Engl J Med 1991;325:445

22. Tools & Techniques
• The benchmark for perioperative stroke or
death for carotid revascularisation is the limit
of 6% for symptomatic pts.
and
• 3% for asymptomatic patients.

23. How to achieve good outcomes…
• 1. A “tailored-approach”-
The application of endovascular
technologies and techniques to a specific-
patient with a specific lesion and vascular
anatomy.

24. • 2. The choice of stent, embolic protection
device (EPD), guidingcatheter and sheath is
strongly dependant on an in-depth knowledge
of neuro-assessment, carotid plaque
characteristics,vascular anatomy and technical
features of a vast array of endovascular
materials.

25. • 3. Experience with a wide range of devices
allows the operator the flexibility to choose
the most appropriate tools and techniques for
the safe application of CAS.

26. Carotid plaque and vascular anatomy
evaluations
• Length/bulk of disease and the morphologic
features that predict lesion complexity such as
degree of calcification and embolisation-
potential (“vulnerable plaque”).
• “soft-lesions”on B-mode ultrasound with
GSM <25.

27. (A) Angiographic aspect of an ulcerated carotid ultrasonographic appearance of
plaque (circle); (B) ulcerated portion in detail; a “soft” plaque

28. The assessment of vascular profile
• 1. Configuration of the aortic arch .
• 2. Arch embologenic-risk in terms of burden of
irregular, ulcerated and calcified atheroma .
• 3. Angulations and tortuosity, coiling and kinking
of supra- aortic trunks .
• 4. Level of carotid bifurcation and its anatomy
regarding angle of take-off of the internal carotid
artery (ICA), tortuosity at lesion-site and vessel
dimensions .
• 5.Intracranial segment of the ICA and
ipsilateral/contralateral cerebral circulation to
determine collateral flow including circle of Willis
and identify abnormal flow patterns.

29. Aortic arch anatomy
Type I (A), Type II (B) and Type III
(C) arches

30. Example of an aortic arch with high emboligenic-risk.
extense, irregular and calcified plaque in the aortic wall

31. Challenging anatomies of the supra-aortic trunks.
A bovine aortic arch configuration is where the LCC originates from the
brachiocephalic trunk

32. Challenging anatomies of the supra-aortic trunks
(C) proximal kinking followed by distal
(A) accentuated tortuosity of the tortuosity of the LCCA,
RCCA; (B) tortuosity of both (D) Kinking of the brachiocephalic trunk
followed by angulated common carotid
common carotid arteries; arteries in a bovine aortic arch.

33. Intracranial ICA and ipsilateral/contralateral
cerebral circulation
A) Right AP intracranial angiogram A severe lesion (red dotted circle) at
. the ostium of the MCA requires
treatment before approaching the
B) Right lateral intracranial carotid bifurcation.
angiogram.

35. Neuroprotection systems
•Embolisation occurs in all percutaneous cardiovascular
Interventions.
•It acquires more significance in the neurovascular territory.
• Carotid lesions contain friable ulcerated plaque and thrombotic
material that can embolise during endovascular or open surgery.
•Embolic particles are classified as either macroemboli (>100 μm)
or microemboli (<100 μm).
•Macroemboli, especially >200 μm, are usually associated with
clinical events;

36. Distal protection devices
• Filter devices can be classified based on the
relationship to the 0.014” guidewire.
“wire-mounted filters”.
“bare-wire filter systems”.
• Filters are positioned in a straight portion
of the ICA(“landing-zone”) in order to
optimise adaptation of the frame to
thevessel wal

37. Schematic of (A) concentric and (B) eccentric filters
illustrating the position of the wire in relation to the
basket.

39. LIMITATIONS OF DISTAL PROTECTION DEVICES
• 1.Unprotected crossing of the lesion in order to
deploy the device,especially in tight stenoses.
• 2.Not effective in trapping microemboli, limited
by pore size.
• 3. In tortuous, large or diseased distal ICA
anatomies incomplete wall apposition may allow
even macroemboli to bypass the system.
• 4. Debris may be dislodged during the recapture
phase (“squeezing effect”) of the procedure.
• 5. Filters may be an embolic source themselves
due to intimal damage at the landing zone.

40. Proximal protection devices
• Proximal occlusion devices interrupt or
reverse blood-flow in the ICA by preventing
antegrade flow from the CCA to the ICA and
retrograde flow from the ECA into the ICA.

41. • they offer the following advantages:
– 1. Crossing the lesion under protection with the
preferred guidewire.
– 2. Blocking both macro- and microemboli.
– 3.Navigation of the device in the distal ICA is not
required, thus reducing the risk of intimal
damage, spasm or dissection.

42. MO.MA™ (INVATEC S.P.A., RONCADELLE, ITALY
9FR sheath with integrated baloon in CCA
EXTENDED INTEGRATED BALOON IN ECA.

43. backpressure of >30 mmHg predicts tolerance to
flow- blockage.

44. Following postdilatation blood is aspirated and checked for debris
before deflatingthe balloons

45. NEUROPROTECTION SYSTEM™ (NPS) (GORE, NEWARK,
DE, USA)
(A) Global view of the system. The detail shows
the “balloon-sheath” and the “balloon-wire” B) The filter is positioned between the
both inflated in the CCA NPS-sheath and the venous sheath. (C) The
and ECA NPS “balloon-sheath”.

46. LIMITATIONS OF PROXIMAL PROTECTION
DEVICES

47. PROXIMAL PROTECTION DURING CAS: CLINICAL OUTCOMES
• The ARMOUR study is a pivotal US trial evaluating the
safety and effectiveness of the Mo.Ma system.
– 30-day major adverse cardiac and cerebrovascular events, was
2.3%. The device success rate was 98.2%.
• The DESERVE study(europe) is a Diffusion Weighted-MRI
based evaluation of the effectiveness of the Mo.Ma
system.
– Results awaited.
• EMPIRE is a prospective controlled single-arm
multicentre trial to evaluate the performance of
the NPS system.
• It enrolled 122 patients .
• The primary endpoint of 30-day stroke and death rate was
1.6%.

48. Carotid stent selection
A) Open-cell design. B) Closed-cell C) Straight and tapered-stent
design configurations.

49. Carotid lesion treated by open-cell stent
showing a high flexibility and conformability that respect the original
anatomy of the vessel.

50. Structural and functional characteristics
• COBALT-ALLOY WIRE.
• Advantages
– flexible delivery system,
– small free-cell area with
high scaffolding and wall-
coverage properties
– adaptability to the
changing diameter across
the bifurcation.
• disadvantaged
– tendency to straighten
the vessel and
foreshortening during
deployment.

52. HYBRID STENTS

53. Functional characteristics of the hybrid carotid
stent(CRISTALLO IDEALE)

54. Carotid stenting step-by-step procedure
• Peri-interventional protocol
– PRE-PROCEDURE INVESTIGATIONS
• 1. Carotid duplex scan. MR or CT angiography is not
mandatory,however, during the early experience it may help plan
for a challenging intervention.
• 2. Independent neurological evaluation.
• PRE-MEDICATION
– Dual antiplatelet therapy with aspirin and clopidogrel, ideally,initiated
five days before the procedure; and continued for at least 30 days at
which time clopidogrel is usually discontinued.

55. GENERAL PROCEDURAL MEASURES
• 1.Head support and no sedation;
• 2.standard monitoring of vital parameters
along with neuro-evaluation during procedure
by simple communication and movement
parameters.
• 3. hydrated and maintain saline infusion.
• 4.Heparin intravenous or intra-arterial 70
U/Kg (ACT 200 to 300 seconds; with proximal
occlusion aim for 250 to 300 seconds).

56. ANTI-HYPERTENSIVE MEDICATION
• Anti-hypertensive medication is omitted on
the day of the procedure and during the early
days postprocedure.
• Restarted once hypotension resolves to
ensure no rebound hypertension.

57. Technique
VASCULAR ACCESS
The femoral approach is strongly recommended, but in
the presence of extreme tortuosity or occlusion of the
iliac arteries the radial/brachial approach is feasible.
• BASELINE ANGIOGRAPHIC EVALUATION.
• Aortic arch angiography is undertaken with a
pigtail catheter (30°to 45° left anterior oblique,
LAO) to determine arch configuration and
embologenic-risk, and visualise the origins of the
supra-aortic vessels.
• 2. Selective bilateral extracranial angiograms.

58. • It is mandatory to perform an intracranial
angiogram.
• Four vessel angiography, carotids and vertebrals,
are indicated only where the complexity of the
case recommends it as mandatory.(adequacy of
the collateral circulation and the function of the
circle of Willis).

59. COMMON CAROTID CANULATION
• safe and stable engagement of the CCA is one of
the most important.
• this is a significant distinction between CAS and
coronary interventions as engagement of the
deep-seated supraaortic trunks is typically more
difficult and requires great expertise.
• JR4 catheter is adequate.
• For Type III arch or an angulated or bovine origin
of the left CCA a JB2 catheter is most commonly
used.

60. • Sometimes in complex Type III or bovine
arches a Simmons catheter is necessary.

61. Guiding catheter engagement
• 90-100 cm 8 Fr guiding-catheter is chosen
according to the aortic arch configuration.
• For complex anatomy an angulated guide such
as a Hockey-stick curve catheter is advanced
into the proximal CCA.
• For simple anatomy a 40° angled soft-tip
catheter is advanced to the mid-CCA over a
soft-angled 0.035” standard hydrophilic wire
positioned just below the bifurcation.

62. • The introduction of two, or possibly three,
0.035” wires in order to advance the catheter
in the presence of an unstable situation is
feasible.
• Sheath placement according to need can be
done after withdrawing guiding catheter over
the support wire.

63. EPD MANAGEMENT
• Distal filters are positioned at least 30 to 40
mm distal to the target lesion.(to avoid
entrapment).
• Full and adequate wall apposition of filter
devices must be confirmed by angiography in
two projections.
• When using distal filter devices it is critical to
always visualise the position of the guiding
catheter.

64. PREDILATATION
• Predilatation is reserved for
 very tight lesions,
 heavily calcified
 long fibrotic lesions.
• low profile coronary balloon.
– 2.5 to 3.5 mm diameter .
– 20 to 30 mm length, and inflated at nominal
pressure.9
– cutting balloon for heavily calcified plaques usually
with a diameter of 3.5 to 4.0 mm and inflated at
moderate pressure (8 atmospheres).

65. • Pre-treatment with 0.5 to 1 mg of intravenous
atropine is required at this stage and/or post
dilatation phase.
• A fundamental principle of balloon dilatation
in CAS is the application of nominal pressure
for a brief period (about five seconds).

66. STENT DEPLOYMENT
 use stents 1 to 2 mm larger than the widest
vessel diameter to be covered.
• The most commonly used stent size with
reference to the proximal CCA edge is 8 to 10
mm.
and
• in the case of tapered stents the most
common reference for the distal ICA edge is 6
to 8 mm.

67. POST DILATATION
• Sizing the balloon according to the ICA at the
distal stent edge to prevent dissection and
squeezing of material through the stent mesh.
• Balloons no larger than 5.5 mm should be
used.
• The most common sizes required are 5.0 and
5.5 mm by a length of 20mm

68. • 10-30% residual stenosis is accepted.
• The stent segment in the CCA does not
require post dilatation.
• If plaque prolapses through the stent struts
(cheese-grater effect) no further balloon
dilatations should be performed and a second
stent, preferably a closed-cell stent should be
implanted.

69. FINAL ANGIOGRAPHIC EVALUATION
• acquired in the same baseline projections.
• If a distal protection device was used the
landing-zone has to checked carefully,
• Ipsilateral intracranial angiography should be
routinely acquired.

70. Complications
• Bradycardia and hypotension.
• Carotid artery spasm.
• Distal embolisation.
• Intracranial haemorrhage.
• Hyperperfusion syndrome.
• Contrast encephalopathy.
• Carotid dissection.
• Carotid perforation.
• External carotid artery occlusion.
• Acute stent thrombosis.
• Restenosis.