How I approach patients with both proximal common carotid disease - - PowerPoint PPT Presentation
How I approach patients with both proximal common carotid disease & carotid bifurcation disease Peter A. Schneider, MD Kaiser Hospital and Hawaii Permanente Medical Group Honolulu, Hawaii DISCLOSURE Peter A. Schneider Enter patients in
Peter A. Schneider, MD Kaiser Hospital and Hawaii Permanente Medical Group Honolulu, Hawaii
Peter A. Schneider Enter patients in studies sponsored by: Gore, Cordis, Medtronic, Silk Road, Bard, NIH, Limflow Modest royalty: Cook Scientific Advisory Board (non-compensated): Abbott, Medtronic, Boston Scientific, CSI Chief Medical Officer: Intact Vascular, Cagent National co-PI: Roadster 2, Scaffold, Confidence, In.Pact
Moore and Schneider. Simin Vasc Surg 2011;24:2
XX XX Multiple options available Dangerous for CEA and CAS Distance between the lesions
Combined Proximal Common Carotid and Bifurcation Disease
§ Options
xxx xxx Needle puncture at inferior aspect of arteriotomy Wire directed into descending aorta xxx Make sure the patient is well anticoagulated. Size the CCA and evaluate the arch with CTA. Beware long lesions-consider inflow bypass instead.
Balloon expandable stent proximal common carotid artery Clamp CCA Lengthen arteriotomy CEA xxx
xxx
5F transfemoral catheter in the arch during stent placement Size the stent by CTA Retrograde contrast injection through a severe arch lesion
Balloon expandable stent placed with slight extension into the arch.
A meta-analysis of combined endarterectomy and proximal balloon angioplasty for tandem disease of the arch vessels and carotid bifurcation
Giorgos S. Sfyroeras, MD, PhD, Christos Karathanos, MD, George A. Antoniou, MD, Vassileios
Sfyroeras et al. J Vasc Surg 2011;54:534
133 patients in 13 studies Prroximal lesion: CCA in 85 , Innominate in 48 Technical success: 97% 79 stents, 50 PTA’s 30 day: stroke 1.5%, mortality 0.7% Follow-up 12-36 months Proximal recurrent stenosis: 7 of 50 (14%) PTA’s, 3 of 79 stents (4%)
Combined Proximal Common Carotid and Bifurcation Disease
Author Patients Age Symptomatic Symptoms (patients) Proximal lesion location Innominate artery CCA Sidhu6 2 72-74 1 Stroke (1) 2 Levien2 44 60.4 8.1 44 TIA (19), amaurosis fugax (9), TIA and amaurosis fugax (5), retinal embolus (3), stable stroke (5), nonhemispheric symptoms (3) 24 20 Sullivan7 5 nr nr 5 Macierewitz8 8 70 (64-78) 8 TIA (6), nondisabling stroke (1), amaurosis fugax (1) 1 7 Arko9 6 74.7 (63-78) 2 Cerebral ischemia (2) 1 5 Greko3 16 70 (56-80) 8 TIA (2), nonfocal cerebral symptoms (6) 6 10 Lutz10 2 nr nr nr 2 Allie11 34 68 9.6 nr nr 11 23 Payne12 8 64 10.8 7 TIA (3), amaurosis fugax (3), nondisabling stroke (1) 2 6 Peterson13 3 nr nr nr 1 2 Basan14 1 71 1 Ocular ischemic syndrome (1) 1 Nakahara15 1 75 — 1 Karathanos16 3 54, 62, 78 2 Stroke (1), TIA (1) 3
Sfyroeras et al. J Vasc Surg 2011;54:534
Author Angioplasty/ stenting Sequence Shunt Sidhu6 2/0 CEA/angioplasty No Levien2 43/0 CEA/angioplasty Selectively Sullivan7 0/5 nr nr Macierewitz8 0/8 Stenting/CEA Yes Arko9 0/6 Stenting/CEA Yes Greko3 0/14 Stenting/CEA Yes Lutz10 0/2 Stenting/CEA nr Allie11 0/33 Stenting/CEA Selectively Payne12 5/3 Stenting/CEA Yes Peterson13 0/3 Stenting/CEA nr Basan14 0/1 CEA/stenting nr Nakahara15 0/1 nr nr Karathanos16 0/3 CEA/stenting Selectively
Combined Proximal Common Carotid and Bifurcation Disease
Illumenati et al. Int J Surg 2018;52:329 Radak et al. Ann Vasc Surg 2017;44:368
Serbian study-18 patients: no stroke or death
Combined Proximal Common Carotid and Bifurcation Disease
Heyn et al. Ann Vasc Surg 2016;34:193
GA CB
Duration of operation [min]
50 100 150 200 250 300 350 GA CB
Duration of cross-clamping [min]
20 22 24 26 28 30 32 34 36 38 40
A B
a significant reduction of operation (A) and cross-clamping time (B) when compared to patients with GA; *P < 0.05.
Munich: 17 patients randomized to cervical block or general anesthesia
Combined Proximal Common Carotid and Bifurcation Disease
Clouse et al. J Vasc Surg 2016;63:1517
Retrograde stenting of proximal lesions with carotid endarterectomy increases risk 30 day stroke and death 9%
Combined Proximal Common Carotid and Bifurcation Disease
Clouse et al. J Vasc Surg 2016;63:1517
Retrograde stenting of proximal lesions with carotid endarterectomy increases risk
23 patients over 11 years, 8 were symptomatic
Bifurcation disease treated first: 21 of 23 (91%) Patch: 87% Dissection at stent site: 3 (13%)-2 required more stents, one stroke-death
Moore and Schneider. Simin Vasc Surg 2011;24:2
Guidewire in the ECA Exchange wire To support sheath PTA of CCA Balloon on the way in to create space for the sheath
xxx xxx xxx
Advance sheath Place filter Carotid stent Remove filter Wire in ECA Withdraw sheath CCA stent
Balloon on the way in Stent on the way out
§ Risk factor for poor outcomes with CAS § Excluded from all carotid stent trials § Need to use a second stent
multiple stents placed (OR 7.7, strongest predictor)
§ Lesion length, Sequential lesions
sequential lesions OR=3.6)
§ Lesion that extends beyond that which can be treated with a
single stent is typically contraindicated by IFU
Caution Against Treating Diffuse Lesions
Bennett et al. J Vasc Surg 2017;66:1093 Moore et al. J Vasc Surg 2016;63:851
62 year old woman left CEA 10 years ago, left carotid-subclavian bypass 6 years ago. Now with symptoms of global hypoperfusion
Angioplasty CCA lesion on the way in and stent on the way out
§ Hybrid: Re-do endarterectomy and retrograde
§ All open: options limited. Inflow? § All endo: Stent CCA with balloon expandable
Sheath Filter Carotid-subclavian bypass
Balloon-expandable stent Angioplasty CCA lesion on the way in and stent on the way out Take out the protection device before backing up sheath
Both proximal common carotid & bifurcation disease
§ Small percentage of cases, but challenging when they present. § Several options for treatment. § Hybrid procedure: CEA plus proximal CCA stent appears to be
safe, but with important caveats.