Carotid Artery Stenting: The Basics (eBook)

PREFACE 7
CONTENTS 8
CONTRIBUTORS 10
I CAROTID ARTERY STENOSIS AND MANAGEMENT 12
Carotid Artery Stenosis Prevalence and Medical Therapy 13
Prevalence of Carotid Artery Stenosis (Extracranial and Intracranial) 13
Incidence and Economic Burden 13
Etiology 14
Prevalence of Concomitant Coronary Artery Disease 15
Risk of Stroke with Coronary Artery Bypass Surgery 15
Correlation of Carotid Stenosis to Strokes 15
Significance of a Carotid Bruit 16
Typical Stroke Syndromes Associated with Extracranial Carotid Stenosis 17
Evidence-Based Medical Therapy for Patients with Carotid Stenosis 17
Primary Prevention of Traditional Cardiovascular Risk Factors 19
Antiplatelet Therapies 19
Aspirin 19
Aspirin and Acute Stroke 21
Dipyridamole 21
Clopidogrel 21
Summary of Antiplatelet Agents 22
Statins 23
Secondary Stroke Prevention 24
ACE Inhibitors 26
Secondary Stroke Prevention 26
Anticoagulants 26
Conclusions 27
References 27
Carotid Revascularization: Carotid Endarterectomy 30
Introduction 30
Preoperative Assessment 31
Indications for CEA 32
Symptomatic Carotid Artery Stenosis 32
Asymptomatic Carotid Stenosis Trials 33
Summary of the Indications 34
Surgical Technique 35
Shunting or Not 37
CEA Under Local Anesthesia vs. General Anesthesia 37
Patch vs. Primary Closure 38
Type of Patch 38
A Variant Approach: Eversion Endarterectomy 38
Complications 39
Early Complications 39
Stroke or death 39
Hyperperfusion/cerebral hemorrhage 39
Cranial nerve injuries 40
Hemorrhage and infection 40
Systemic complications 40
Late Complications 40
Recurrent stenosis 40
False aneurysm 41
Conclusions 41
References 41
Carotid Stenting Registries and Randomized Trials 46
Introduction and Historical Background 46
Early Multi-Center Cas Registries 48
Pro-CAS 49
ELOCAS 49
The Global Carotid Artery Stent Registry 49
Contemporary High Surgical Risk Cas Registries 50
ARCHeR 50
BEACH 52
CABERNET 52
CREATE 53
MAVErIC 53
MO.MA 53
PASCAL 54
PRIAMUS 54
SECURITY 54
Trials of cas vs. Cea 54
The ‘Stopped’ Trial 55
CAVATAS 55
The Wallstent Trial 55
Community (Kentucky) Trial 56
CARESS 56
SAPPHIRE 57
EVA-3S 59
SPACE 61
Meta-analyses of CAS vs. CEA Trial Data 63
Post-Market Surveillance (Pms) Registries 64
CAPTURE 65
CASES-PMS 65
EXACT 66
Ongoing trials of cas vs. Cea 66
CREST 66
ICSS/CAVATAS-2 67
Act-1 68
ACST-2 68
TACIT 68
Conclusion 68
References 69
II LABORATORY SETUP AND BACKGROUND NONINVASIVE IMAGING 73
Catheterization Laboratory: X-Ray Equipment, Imaging Modalities and Programs, and Radiation Safety 74
Introduction 75
Imaging Equipment 75
Intravascular Contrast Agents 76
Imaging Modalities and Programs 77
Radiation Safety 81
Conclusions 82
References 82
Noninvasive Imaging of the Extracranial Carotid Circulation 83
Introduction 83
CT Angiography 83
CT Technique 84
Influence of Scan Speed 84
Contrast Injection Protocols 84
Image Reconstruction 84
Image Interpretation 88
CT Artifacts 88
Validation Studies of CT Angiography 88
MR Angiography 88
Time-of-Flight MRA 89
Contrast-Enhanced MRA 92
Gadolinium 92
MRA Validation 93
Carotid UltraSonography 93
Other Applications for Carotid Sonography 97
Carotid Near and Total Occlusion 98
Recommendations Regarding Imaging 98
References 98
III PATIENT AND OPERATOR PREPARATION FOR CAROTID STENTING 101
Pre-procedural Patient Preparation 102
Introduction 102
Baseline Neurological Examination 103
NIH Stroke Scale 103
Adjusting Medications Prior to the Procedure 107
Medication Adjustment Prior to Contrast Agents Use 107
Medication Adjustment Prior to Carotid Intervention 107
Use of Antiplatelet Agents Prior to and Following CAS 108
Aspirin 108
Thienopyridines 108
Use of Anticoagulants with CAS 109
Use of Unfractionated Heparin (UFH) 109
Use of Low Molecular Weight Heparins (LMWH) 110
Direct Thrombin Inhibitors 111
Use of Glycoprotein IIb/IIIa Inhibitors 112
Conclusion 112
References 112
Patient Selection for Carotid Stenting 115
Introduction 115
Atherothrombotic Risk Profile in Patients with Cerebrovascular Disease 116
Carotid Endarterectomy 117
Carotid Artery Stenting vs. Carotid Endarterectomy 118
Special Populations 120
Contraindications to Carotid Stenting 121
Indications for Carotid Revascularization 121
Screening for Carotid Artery Disease 122
Reimbursement Considerations for Carotid Stenting 122
Considerations for Training and Credentialing 122
References 122
Operator Training and Accreditation 125
Introduction 126
Training Pathways 126
Preliminary Training 127
Cognitive Skills And Knowledge Base 128
Technical Skills 129
Cerebral Angiography 129
Carotid Intervention 130
Maintenance Of Continuing Quality Of Care 132
Role Of Simulation 132
Summary 132
References 133
IV TECHNICAL APPROACH OF CAROTID ARTERY STENTING 134
Vascular Access: Femoral, Radial, Brachial, and Direct Carotid Approach 135
Introduction 135
General Principles 136
Femoral Access 137
Indications/Contraindications 137
Methods 137
Landmarks 137
Puncture 138
Hemostasis 140
Closure 140
Complications 141
Radial Access 141
Indications/Contraindications 141
Methods 142
Complications 144
Brachial Access 144
Indications/Contraindications 144
Methods 145
Complications 146
Direct Carotid Access 146
Indications/Contraindications 146
Methods 147
Complications 148
Summary 148
References 149
Aortic Arch and Cerebrovascular Anatomy and Angiography 151
Introduction 151
Great Vessel and Cerebrovascular Anatomy 152
The Aortic Arch 152
The Subclavian Arteries 154
The Anterior Circulation 154
Common Carotid Arteries (CCA) 154
External Carotid Artery (ECA) 155
Internal Carotid Artery (ICA) 156
Middle Cerebral Artery (MCA) 158
Anterior Cerebral Artery (ACA) 158
The Posterior Circulation 160
Vertebral Arteries 160
Basilar Artery 162
Posterior Cerebral Artery (PCA) 165
Circle of Willis 165
Great Vessel and Cerebrovascular Angiography 166
Basic Principles 166
Arterial Access 166
Anticoagulation, Catheter Preparation and Contrast Agents 167
Aortic Arch Angiography 167
Selective Carotid Angiography 168
Vertebral Angiography 169
Reverse-Curve Diagnostic Catheters 170
Complications of Cerebrovascular Angiography 170
Conclusions 170
References 171
Extracranial Carotid Stent Interventional Approach 172
Introduction 172
Carotid Artery Stenting Procedure 173
Arterial Access 173
Anticoagulation 173
Baseline Diagnostic Carotid and Cerebral Angiography 173
Sheath or Guide Approach 176
Sheath Approach 177
Guide Approach 179
Direct Guide Approach 180
Emboli Protection Device 180
Filter EPD 180
Balloon Occlusion EPD 182
Balloon Pre-dilatation 185
Stent Placement 186
Balloon Post-dilatation 188
Retrieval of EPD 188
Final Carotid and Cerebral Angiography 190
Post-Procedural Monitoring 190
Contralateral Carotid Stenosis 192
Conclusion 192
References 192
Equipment for Extracranial Carotid Artery Stenting 194
Introduction 194
Guidewires 195
0.014" or 0.018" Guidewires 195
0.035" Peripheral Guidewires 195
Flexible Peripheral Wires 195
Hydrophilic Peripheral Wires 197
Stiff Peripheral Wires 197
Catheters and Sheaths 198
Diagnostic Catheters: Types I and II Aortic Arch 198
Diagnostic Catheters: Type III Aortic Arch 199
Guide Catheters 199
Sheaths 199
Angioplasty Balloons 200
Pre-dilatation Balloons 200
Post-dilatation Balloons 201
Carotid Stents and EPD 201
Open Versus Closed Strut Stent Design and Rationale 202
ACCULINKtrade, RX-ACCULINKtrade Stents and ACCUNETtrade EPD 204
XACTreg Stent and Emboshieldreg EPD 205
Protégéreg GPStrade, Protégéreg RX Stents, and SPIDERtrade EPD 207
PRECISEtrade Stent and Angioguardreg XP EPD 208
Nexstentreg Stent and Filterwire EZtrade EPD 209
Exponentreg OTX, Exponentreg RX, and Guardwiretrade EPD 209
Aspiration Catheters 211
Proximal Balloon Occlusion Emboli Protection Devices 211
Conclusion 213
References 214
The Endovascular Treatment of Acute Ischemic Stroke 215
Introduction 215
The Uniqueness of the Cerebrovascular Circulation 216
Acute Ischemic Stroke Treatment 217
Patient Selection 218
Interventional Approach 221
Diagnostic Angiography 221
Access 222
Recanalization Technique 224
Adjunctive Pharmacotherapy 226
Clot Disruption 226
Clot Extraction 227
Peri-procedural Medical Management 231
Conclusion 234
References 234
V COMPLICATIONS AND POST-PROCEDURAL MONITORING 237
Complications Related to Carotid Stenting 238
Introduction 238
Factors Affecting Complication Rates Of Carotid Revascularization 239
Overall Complication Rates 240
Prevalence of Major Complications (Death, Stroke, and MI) 240
Procedural Complications 242
Vascular Access Complications 242
Ischemic Embolization 244
Slow Flow/No Reflow/Abrupt Vessel Closure 246
Retinal Artery Embolization 248
Reflex Bradycardia and Hypotension 249
Post-Procedural Complications 250
Delirium 250
The Hyperperfusion Syndrome 251
Stent Thrombosis 251
Late Distal Embolization 252
Restenosis 252
Contrast-Induced Nephropathy 253
Stent Deformity 255
Conclusion 255
References 256
Post-Procedural Monitoring and Follow-Up 260
Introduction 260
Procedural And Early Post-Procedural Monitoring 261
Cardiovascular Hemodynamic Monitoring 262
Reflex Hypotension 263
Reflex Bradycardia 263
Hyperperfusion Syndrome 263
Neurological Monitoring 264
Neurological Complications 265
Retinal Embolization 265
Pre-Discharge Investigations, Medications, And Follow-Up 265
Carotid Doppler 265
Medications 266
Conclusion 266
References 266
INDEX 268