[PPT] - Carotid Artery Stenting: Procedural Complications Aman B. Patel, MD PowerPoint Presentation

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Carotid Artery Stenting:

Procedural Complications

Aman B. Patel, MD Massachusetts General Hospital Harvard Medical School

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Disclosure Statement of Financial Interest

Consulting Fees/Honoraria
Covidien
Penumbra

Within the past 12 months, I have had a financial interest/arrangement or affiliation with the organization(s) listed below.

Affiliation/Financial Relationship Company

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Outline

Pre- EPD
Stent Deployment
Post Stent Deployment

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Embolic Stroke

Catheterization
Crossing the Lesion
Angioplasty – pre or post
Placement of Stent
Retrieval of EPD

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Embolic Stroke

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202±119 52±64 Number of hits CAS CEA Procedure

Crawley F, Clifton A, Buckenham T, et al.. Stroke 1997

Quantification of emboli Transcranial Doppler

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Protection Devices

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Stroke and death rate within 30 days = 1.8% with protection

compared with 5.5% without protection (P<0.001).

Mainly due to a decrease in occurrence of minor strokes (3.7%

vs 0.5%; P<0.001) and major strokes (1.1% vs 0.3%; P<0.05), whereas death rates were almost identical (0.8%; 20.3, P=0.6).

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Protection Device

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Carotid Artery Stenting Impact of NeuroProtection – Global Registry

0.8 .82 1.6 .61 2.8 .86 0.4 .45 0.7 .72 1. 1.1 1 2 3 4 5 6 Un Unprotected Pr Protect cted Mino nor s stroke Majo jor S Stroke De Death N = 6,688 cases ses 4,005 cases es

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Protection Device Limitations

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Large profile
Abrupt change in

stiffness

Capture efficiency

– Pore size (>100uM) – Incomplete occlusion – Filter retrieval

Dissection

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Embolic Stroke - Management VS

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Embolic Protection Device - Issues

Vessel Occlusion

Casserly, I; et al: JACC 2005 Volume 46, Issue 8, 2005, 1466–1472

Embolic protection device can lead to slow flow, hypoperfusion injury,

thrombosis

9% in a single center retrospective review.

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Vasospasm

Navigating the vessels: Hemodynamically significant spasm in 3-5 % of cases

Tex Heart Inst J. 2010; 37(2): 226–229.

Embolic Protection Device

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Vasospasm - Management

Removal of device and time
IA Nitro 100 microgram aliquouts
IA Verapamil 10 mg aliquouts
IA Nicardipine
Look for vessel injury/dissection, distal emboli

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Stent Deployment Complications

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Bradycardia and Hypotension

Rates range from 10-42%
Associated with: older age, female, MI, CAD, stenosis at

carotid bulb

Drug Intervention required in ~ 50% sypmtomatic patients

AJNR November 2008 29: 1942-1947

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Managing Bradycardia Hypotension

Arterial Line
Communication with Anesthesia team
Atropine/Glycopyrrolate at time of angioplasty
Volume versus pressors at time of treatment
Monitoring 6-12 hours following procedure

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Stent Deployment

In stent thrombosis: 0.5-5% in early devices, 0.04-2% with modern anti-platelet regimen.

Sabine Steiner-Böker et al. AJNR 2004;25:1411-1413

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Stent Thrombosis

Acute
IA IIB/IIIA inhibitors followed by IV drip
Mechanical thrombectomy with aspiration
Delayed
? Thrombosis vs restenosis
? Platelet aggregation vs thrombus
IA treatments with IIB/IIIA or tPA or aspiration
IV heparin to stabilize the clot

Sabine Steiner-Böker et al. AJNR 2004;25:1411-1413

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Other stent issues

Vasospasm
Placement in tortuosity
Significant vessel size mismatch
Tx if needed with IA vasodilators
Dissection
Can be treated medically in most instances
If flow limiting consider placement of additional stent

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Post-Deployment: Hyperperfusion

Hyperperfusion syndrome and Hemorrhage Rare (0.67%)

Journal of the American College of Cardiology. 2004;43(9):1596–1601.

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Post-Deployment: Hyperperfusion

Increase in perfusion of 100% compared to baseline
Clinical signs: Somnolence, Headache, Seizure, Signs of

increased ICP, aphasia, weakness.

Within 12 hours to days following procedure
10-24% of cases of syndrome
0.6-0.8% of cases with ICH
Risks
Diabetes, Age, recent contralateral procedure,

incomplete COW, high grade stenosis, post-op hypertension

J. Vasc Surg 2009 Apr;49(4):1060-8.

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Post Stent Deployment

Inability to recapture EPD
Most instances related to inability to pass retrieval

catheter through stent

Head rotation, extension, manual displacement of

carotid with external force

Consider 4F or 5F catheter with angled tip to retrieve
device. Angled tip allows for rotating around turns

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Post Stent Deployment

Femoral Pseudoaneurysm: approximately 3% of patients

Jpn. J. Vasc. Surg., 13: 1-6, 2004

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Delayed: Stent Fracture

J. Vasc Surg. 2010 Jun;51(6):1397-405.
11 of 312 at 1 year follow-up (3.4%)
Associated with Calcification and vessel angulation
Correlated with restenosis following stent

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Conclusions

Overall Safe Procedure
Acute risks still less than that of open surgery
Risks Decrease with increased use and

Technology improvements

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Citations

1.Abou-Chebl A, Yadav JS, Reginelli JP, Bajzer C, Bhatt D, Krieger DW. Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: Risk factors, prevention, and treatment. J Am Coll Cardiol. 2004;43:1596-1601 2.Brott TG, Howard G, Roubin GS, Meschia JF, Mackey A, Brooks W, et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med. 2016;374:1021-1031 3.Casserly IP, Abou-Chebl A, Fathi RB, Lee DS, Saw J, Exaire JE, et al. Slow-flow phenomenon during carotid artery intervention with embolic protection devices: Predictors and clinical outcome. J Am Coll Cardiol. 2005;46:1466-1472 4.Coppi G, Moratto R, Veronesi J, Nicolosi E, Silingardi R. Carotid artery stent fracture identification and clinical relevance. J Vasc Surg. 2010;51:1397-1405 5.Lin PH, Zhou W, Kougias P, El Sayed HF, Barshes NR, Huynh TT. Factors associated with hypotension and bradycardia after carotid angioplasty and stenting. J Vasc Surg. 2007;46:846-853; discussion 853-844 6.Moulakakis KG, Mylonas SN, Sfyroeras GS, Andrikopoulos V. Hyperperfusion syndrome after carotid revascularization. J Vasc Surg. 2009;49:1060-1068 7.Reimers B, Corvaja N, Moshiri S, Sacca S, Albiero R, Di Mario C, et al. Cerebral protection with filter devices during carotid artery

stenting. Circulation. 2001;104:12-15

8.Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med. 2016;374:1011-1020 9.Steiner-Boker S, Cejna M, Nasel C, Minar E, Kopp CW. Successful revascularization of acute carotid stent thrombosis by facilitated thrombolysis. AJNR Am J Neuroradiol. 2004;25:1411-1413 10.Taha MM, Sakaida H, Asakura F, Maeda M, Toma N, Sano T, et al. Access site complications with carotid angioplasty and stenting. Surg Neurol. 2007;68:431-437 11.Vijayvergiya R, Otaal PS, Bagga S, Modi M. Symptomatic carotid vasospasm caused by a distal-protection device during stent angioplasty of the right internal carotid artery. Tex Heart Inst J. 2010;37:226-229 12.Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351:1493-1501

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Thanks

Jpn. J. Vasc. Surg., 13: 1-6, 2004