Tough Arches, Tough Access, and Alternate Access Sasko Kedev - - PowerPoint PPT Presentation

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Tough Arches, Tough Access, and Alternate Access Sasko Kedev - - PowerPoint PPT Presentation

Oct 13, 2023 284 likes •1.1k views

Carotid Stenting Technique: Tough Arches, Tough Access, and Alternate Access Sasko Kedev University Clinic of Cardiology- Skopje Macedonia Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a

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Carotid Stenting Technique: Tough Arches, Tough Access, and Alternate Access

Sasko Kedev

University Clinic of Cardiology- Skopje Macedonia

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Disclosure Statement of Financial Interest

  • Consulting Fees/Honoraria
  • Biotronic
  • Boston Scientific
  • Medtronic
  • Meril

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

Affiliation/Financial Relationship Company

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Why alternative access for CAS ?

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➢ Aorto-iliac disease or occlusion ➢ Previous surgical bypass at this level ➢ Diseased and Complex aortic arch with ➢ Tortuous SAA originating from elongated,

  • r type II, III, or bovine aortic arch

Femoral approach limitations

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Aorto-iliac disease or occlusion

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Tortuous SAA originating from elongated or bovine aortic arch

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The most common adverse event after CAS from the femoral approach MOST TECHNICAL FAILURES ARE RELATED TO A COMPLEX ARCH

Access site complications

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Karalis DG et al. Am Heart J. 1996 Jun;131(6):1149-55.

Risk of catheter-related emboli from aortic atherosclerotic debris

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➢ Brachial ➢ Radial / Ulnar ➢ Direct puncture of carotid artery

Alternatives to femoral access for CAS

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➢

Radial artery

➢

Aortic arch, CCA takeoff

➢

Carotid lesion Tailored approach

Transradial CAS

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➢ Tortuous Internal Carotid Artery ➢ String Sign ➢ Contralateral Occlusion ➢ Acute Carotid Syndrome

Wrist access (radial & ulnar) for CAS

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➢ Anchoring technique

➢ Telescopic approach

Transradial CAS

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Case 1.

Left ACC 100%

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RICA

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Terumo advantage wire in RECA

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Amplatz stiff wire in RECA

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Destination sheath 6Fr

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Destination sheath 6Fr

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Final result

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Before / After

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RRA CAS of LICA in highly symptomatic patient with amaurosis fugax

Male

  • K. G.

64 y.o.

Case 2.

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LICA 99% + dissection/ thrombus

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“ Wireless” telescopic approach

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Shuttle sheath 5F

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Final result

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Before / After

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1 Month follow up

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➢ Right wrist access

➢ Left wrist access

Transradial CAS

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LRA CAS of RICA with contralateral occlusion

Male

  • T. B.

80 y.o

Case 3.

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Right RA

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Occlusion of right subclavian artery

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Left RA

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RCCA/ RICA 99%

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Final result

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RUA CAS of RICA with contralateral occlusion

Male

  • C. T.

63 y.o

Case 4.

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LICA occluded

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RICA

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Stent Roadsaver 8.0/25

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Paladin system

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Final result

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Male

  • K. A.

58 y.o.

TRA CAS of LICA in patient with Acute Carotid Syndrome

Case 5.

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Right RA

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After additional vasodilators

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Thrombotic subocclusion of LICA

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Destination 5F

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Final result

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Final result

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Before / After

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RRA CAS of LICA in symptomatic patient

  • Triple protection

Male

  • K. P.

79 y.o.

Case 6.

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Severe clinical spasm of tortuous RA

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Hydrophilic wire crossing

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Hydrophilic wire crossing

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Catheter crossing

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5F Destination: LICA 99%

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  • 1. NAV 6
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  • 2. Stent: Roadsaver
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  • 3. Paladin system
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Final result

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Female

  • P. G.

49 y.o.

RRA CAS of bovine arch LICA and ipsilateral IC aneurysm

Case 7.

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RRA: 6F Shuttle sheath

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Xact 8-6/30

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6F soft GC

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Male

  • S. P.

59 y.o.

Right RA CAS of LICA With MoMa Proximal Protection

Case 8.

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Right RA

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LICA 95%

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8F - MoMa PPD

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MoMa PPD

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Final result

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➢ Significant learning curve for new TRA operators ➢ Sometimes longer procedure for “easy case”

with type I aortic arch

➢ Proximal PD and larger devices could not

be used freely in all cases

➢ Radial artery occlusion ≈ 10 %

DISADVANTAGE

Wrist access (radial & ulnar) CAS

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➢ Perform TRA occasionally! ➢ Perform TRA only when FA is not possible!

Wrist access (radial & ulnar) CAS

MISTAKE

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➢ Wrist access for CAS is feasible and safe when performed by experienced RA operator ➢ Easy access for CAS in in complex aortic arcs- bovine arch LCCA and most of the innominate artery take offs ➢ Allows early patient mobilization ➢ Eliminates access site bleeding complications ➢ Further studies are needed before recommending wrist access for CAS as primary approach

Conclusions