Step By Step Tips for the MICHI (Silk Road Medical) Direct Carotid - - PowerPoint PPT Presentation

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Step By Step Tips for the MICHI (Silk Road Medical) Direct Carotid - - PowerPoint PPT Presentation

Dec 27, 2023 289 likes •526 views

Step By Step Tips for the MICHI (Silk Road Medical) Direct Carotid Access System Dr Sumaira Macdonald , MBChB (Comm.), FRCP, FRCR, PhD, EBIR Consultant Vascular Radiologist & Honorary Clinical Senior Lecturer, Freeman Hospital, Newcastle,

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Step By Step Tips for the MICHI (Silk Road Medical) Direct Carotid Access System

Dr Sumaira Macdonald, MBChB (Comm.), FRCP, FRCR, PhD, EBIR Consultant Vascular Radiologist & Honorary Clinical Senior Lecturer, Freeman Hospital, Newcastle, UK

TCT 2012

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Disclosures:

Research / Educational Grants & / or consultancy: Abbott Vascular CR Bard Ev3/Covidien Pyramed WL Gore Medtronic / Invatec Biotronik Cordis (J & J) St Jude/AGA Spectranetics Tryton Medical Silk Road Medical Terumo Merit Medical Volcano COOK Vascular Perspectives Bridgepoint / EPS vascular

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Lecture Plan:

  • Why might an interventionist with:
  • & 13 years of specific transfemoral CAS experience
  • 16 years of general transfemoral access experience

Wish to move to direct carotid access ?

  • To explore tips & tricks from a second-in-man

world-wide experience

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Rationale:

MICHI (Silk Road Medical) Direct Carotid Access System

  • The potential of new technology to solve the remaining

issues for CAS:

  • Learning curve issues (femoral route, complex

catheterization for novices)

  • Minor stroke excess when compared to CEA
  • Excess microembolic burden when compared to

CEA

  • Anatomic constraints from a femoral route, with

distal - filter protection i.e. “standard” CAS

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Study Procedure Embolic Protection # subjects % w/ New DWI Lesions ICSS1 Transfemoral CAS Distal filter (various) 51 73 ICSS1 CEA Clamp, backbleed 107 17 PROFI2 Transfemoral CAS Distal filter (Embosheild) 31 87 Leal4 Transfemoral Distal Filter (FilterWire) 33 33 PROFI2 Transfemoral CAS Proximal

  • cclusion

(MoMA) 31 45 PROOF3 Transervical CAS High flow rate flow reversal 48 16.7 Leal4 Transervical CAS Flow Reversal 31 12.9

1 Lancet Neurol. 2010 Apr;9(4):353-62

  • 2. J Am Coll Cardiol. 2012;59:1383-1389
  • 3. JVS 2011;54:1317-1323
  • 4. JVS 2012 In Press
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Michi System FAST-CAS

Caution: Investigational use in the US

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The Top Ten; Technical Tips & Tricks:

  • 1. Sedation considerations: IV conscious sedation is

unpredictable

  • Overnight hypnotics (Zopiclone – Lunesta) & oral

benzodiazepines at 0600 hours on the morning of the procedure

  • Liberal infiltration of LA above the clavicle at the

proposed cut-down site before surgeon, interventionist

  • r patient preparation
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Technical Tips & Tricks:

  • 2. Neck length considerations:

The Top Ten;

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Avoid “ guestimates ” on CTA

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Ball – bearing marks the lesion Working length – only 4.5cm

Ultrasound is the most accurate measurement

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Technical Tips & Tricks:

  • 3. Head Position:

The Top Ten;

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Technical Tips & Tricks:

  • 4. Surgical Access:

Rummel Loop Side biting clamps

The Top Ten;

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Technical Tips & Tricks:

  • 5. Surgical Pre-Closure Considerations:

The “U” stitch

The Top Ten;

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Technical Tips & Tricks:

  • 6. Facilitating Arterial Sheath Access:

Gentle traction on the Rummel loop Serial diltatation – 6, 8F

The Top Ten;

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Technical Tips & Tricks:

7 . Perfect first-time venous access: Ultrasound guidance

The Top Ten;

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Technical Tips & Tricks:

  • 8. Cross-patient device working:

R CCA to L CFV or vice versa

R CCA L CFV

The Top Ten;

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Technical Tips & Tricks:

  • 9. Wire Management:

Ipsilateral ECA access might facilitate secure placement

  • f the 10F outer diameter arterial sheath when there is

short “ neck length ”

The Top Ten:

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Technical Tips & Tricks:

  • 10. Hemostasis:
  • “U” stitch closure
  • “ Mini-vac ” drain
  • Wait 10 minutes before subcuticular sutures (whilst

applying pressure to the venous access site)

  • Sit the patient at 45 as soon as possible
  • “ D-Stat Dry ” or other hemostatic dressing

The Top Ten;

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Conclusions:

“Standing on the shoulders of giants*”

*Bernard of Chartres 12th Century AD

  • Direct carotid access with high flow rate flow-reversal

may address a number of the remaining issues of CAS

  • The learning curve of any new technique may be blunted

by attention to detail

  • The early adopters can learn from the pioneers

(Düsseldorf), in conjunction with good clinical & technical support (SRM)

  • The ROADSTER US IDE trial is enrolling US sites now –

some of the early lessons learnt should improve procedural practicality

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