Carotid artery stenting – How do I do it

1. Vipul Gupta
Neurointerventional Surgery
Artemis Hospital, Gurgaon

2. IndicationsIndications
Symptomatic StenosisSymptomatic Stenosis
Non-invasive >70%Non-invasive >70%
Catheter angiography >50%Catheter angiography >50%
 Peri-procedural risk <6%Peri-procedural risk <6%
Asymptomatic StenosisAsymptomatic Stenosis
 >70% Stenosis>70% Stenosis
 Periprocedural complication risk is lowPeriprocedural complication risk is low
 Life expectancy >5 yrLife expectancy >5 yr
 > 80% stenosis- tend to be treated> 80% stenosis- tend to be treated
Revascularization indications-Revascularization indications-
ASA/AHA guidelines 2011ASA/AHA guidelines 2011

3. Technique
•Anti-platelet drugs (for 3-5 days)
•Local anaesthesia
•Complete angiogram
•Guide catheter in common carotid
artery
•Cross the stenosis with wire
•Place protection device
•Pre-dilatation with small balloon
•Stent placement (self expanding)
•Post-dilatation, if need be
•Removal of protection device and
sheath

5. Severe stenosis – pre angioplasty

6. Calcification – unless concentric , not an issue

7. Collapsed artery – flow phenomenon

8. Risk reduction in CAS
 Volumes , training
 Planned procedure – CT angiogram
 Anti-platelet – ecospirin, Plavix (double dose)
 “Co-axial” placement of “long sheath”
 Mostly closed cell stent use , filter device
 Monitor for 10-15 min for clots
 Careful use of anti-coagulants- usually taper off, in case with
ulcerated plaques may give clexane
 High risk case for hyperperfusion- severe stenosis, lack of
COW, hypertension
 Selected cases – Venous access, Pacing device
 Neurological and haemodynamic monitoring

9. Results are operator dependent
!!!

12. A B C
D E GF

13. A B C BA

14. D

15. Protection devices

16. Protection devices
 Two small trials randomized CAS patients to filter type EPDs or to no
EPDs and found no difference in the rate of DWI-MRI lesions
(Macdonald S, et alCerebrovasc Dis 2010; Barbato JE et alJ Vasc Surg 2008)
 However, in a review of 134 published reports, including 24 studies
that included data on both protected and unprotected CAS, the
relative risk (RR) for stroke reduction was 0.59 (95% CI 0.47–0.73) in
favor of protected CAS (P<0.001) (Kastrup A, et al Stroke 2006)
 These data have been confirmed in a meta-analysis that found a
lower risk for stroke or death when an EPD was used (RR1⁄40.57; 95% CI
0.43–0.76, P<0.01) (Douse E et al. Stroke 2009)
 The benefit for protected CAS was evident in both symptomatic (RR
0.67; 95% CI 0.52–0.56) and asymptomatic (RR 0.61; 95% CI 0.41–
0.90) patients (P < 0.05) (Garg N et al. J Endovasc Ther 2009;16:412–427)

17. CAROTID STENTING
WITH MOMA DEVICE

19. Distal tortuosity

20. CAROTID STENTING WITH PROXIMAL
FILTER PLACEMENT

21. Carotid stenting
As the technology advanced
 Self expanding stents
 Protection devices
Low profile systems
Protection
device

22. Anti-platelet drug resistance !!!

23. Thrombus …CEA

24. Stenosis with clots.....
After 10-days of heparin

25. Complications
 TIA, stroke (due to emboli)
 Bradycardia/hypotension
 Hyperperfusion syndrome
 Groin complications, contrast
allergy, renal failure
 Complication rate- 2-8%,
improving, operator dependent
 Restenosis (5%-10%)

26. White Cj et al. Cath & Card Vasc Int , 2013

31.  Severe left hemicranial headache
 Seizures- status epilepticus
 Right hemiparesis
Postprocedure day 14

32. CAS vs CEA- CREST – NEJM 2011
•2502 patients- Outcome largely same
•More MI in surgery ; more minor strokes in CAS
•Stenting better in 70yrs and less age group
•Nerve palsies not included in end-points
•Less than 1% major stroke
ASA/AHA guidelines 2014-
Endarterectomy and stenting are
alternatives (Class I evidence)
<70 yrs, stenting may be preferable

33. Sub-analysis of CREST
 Minor strokes recover
 MI not benign
 Cranial nerve injuries in CEA cannot not be
ignored
 Stenting results kept improving during the
trial period- learning curve remains important

34. Complication avoidance-
CEA preferred
 Excessive tortuosity
 Any doubt of thrombus
 Difficulty in placing protection device
 Concentric calcification
 Patient needs CABG as well
 Intolerance to anti-platelet drugs
“No acrobatics, low threshold for referral
for CEA; frequent group discussions”

35. TIMING -Transient ischaemic attack
•Meta-analysis of 11 observational studies:
Risk of stroke at 2, 30 and 90 days afterTIA was 9.9,
13.4 and 17.3% respectively
•Pooled analysis of 3206 pts withTIA and DWI
imaging, risk of stroke at 7 days was much lower in
those without infarction compared to those with
infarction: 0.4% vs 7.1%
Coull et
al. BMJ
2004
Minor
Cerebrovascular
Syndrome

36. TIAs/minor stroke
 High risk of stroke in first few weeks
 Patients with DWI lesions and arterial stenosis
have higher risk
 Revascularization should be done soon

37. ASYMPTOMATIC STENOSIS
1% risk
European society of vascular surgery, 2013
Perirocedural risk (with in 30 days) stroke/MI/death – 1 %

38. • Microemboli
• Plaque morphology
• Vasomotor reactivity
• Silent infarcts
• Progression

39.  CAS – safe procedure in selected
 Protocol based approach
 Currently- filter with closed cell stents
 Low threshold for cross–referral
 Selective asymptomatic

41. Thank you ….