Vipul GuptaNeurointerventional SurgeryArtemis Hospital, Gurgaon

IndicationsIndications Symptomatic Stenosis Symptomatic Stenosis Non-invasive >70% Non-invasive >70% Catheter angiography >50% Catheter angiography >50% Peri-procedural risk <6%Peri-procedural risk <6%

Asymptomatic Stenosis Asymptomatic Stenosis >70% Stenosis>70% Stenosis Periprocedural complication risk is low Periprocedural 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

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

Severe stenosis – pre angioplasty

Calcification – unless concentric , not an issue

Collapsed artery – flow phenomenon

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

Results are operator dependent !!!

A B C

D E GF

A B C BA

D

Protection devices

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)

CAROTID STENTING WITH MOMA DEVICE

Distal tortuosity

CAROTID STENTING WITH PROXIMAL FILTER PLACEMENT

Carotid stentingAs the technology

advanced Self expanding stents Protection devices Low profile systems

Protection device

Anti-platelet drug resistance !!!

Thrombus …CEA

Stenosis with clots.....

After 10-days of heparin

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%)

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

Severe left hemicranial headache Seizures- status epilepticus Right hemiparesis

Postprocedure day 14

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

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

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”

TIMING - Transient ischaemic attack •Meta-analysis of 11 observational studies: Risk of stroke at 2, 30 and 90 days after TIA was 9.9, 13.4 and 17.3% respectively•Pooled analysis of 3206 pts with TIA 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

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

ASYMPTOMATIC STENOSIS

1% risk

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

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

CAS – safe procedure in selected Protocol based approach Currently- filter with closed cell

stents Low threshold for cross–referral Selective asymptomatic

Thank you ….