颈动脉支架技术.pdf

Robert M.Bersin,MD FACC FSCAIRobert M.Bersin,MD FACC FSCAIDirector,Endovascular Services and Clinical ResearchDirector,Endovascular Services and Clinical ResearchSeattle CardiologySeattle CardiologyCardiovascular Consultants of WashingtonCardiovascular Consultants of WashingtonSeattle,WashingtonSeattle,WashingtonCardiovascular Consultants of WashingtonCardiovascular Consultants of WashingtonCarotid Carotid StentingStenting Equipment Equipmentand Techniqueand TechniqueRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Disclosure InformationTechnique of Carotid Technique of Carotid StentingStentingRobert M.Bersin MD,FSCAIRobert M.Bersin MD,FSCAIThe following relationships exist related to this presentation:Name of Company:Boston Scientific AB,C,GS,P,SBName of Company:Bristol-Myers Squibb C,SBName of Company:Cordis Endovascular AB,C,EI,P,SB,SEName of Company:E.I Lilly C,SBName of Company:ev3 PName of Company:Guidant Corporation C,PName of Company:The Medicines Company SBName of Company:Sanofi-Aventis C,SBName of Company:Vascular Architects SOName of Company:Vascular Solutions AB,C,SOOff label use of products will be discussed in this presentation:investigational carotid stent systemsAB:Advisory BoardC:Consulting RelationshipEI:Equity InterestGS:Grant SupportP:Proctor or Training Course SponsorshipsSB:Speakers BureauSE:Spouse EmployeeSO:Stock Options or PositionsRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Stent Trial MedicationsNAAs neededfor thrombus,Warfarin Rx70 U/Kg ACT250-300 secNAHeparinNotrecommended250 mg BIDtwo weeks250 mg BID250 mg BIDTiclopidineNot required75 mg two tofour weeks300-450 mg 4hrs prior75 mgClopidogrel81-325 mgindefinitely81-650 mg81-650 mg81-650 mgAspirinPost-Procedure30 daysPost-Procedure?30 daysDay ofProcedurePre-Procedure2-3 daysMedicationACT I,ACT I,ARCHeRARCHeR,BEACH,CABERNET,CREATE,CREST,BEACH,CABERNET,CREATE,CREST,MAVERiCKMAVERiCK,SAPPHIRE,SAPPHIRE,SECuRITYSECuRITYFatal Carotid Stent ThrombosisLack of Combination Lack of Combination AntiplateletAntiplatelet Therapy TherapyIntraproceduralIntraproceduralASA OnlyASA Only72 Hrs Post-Stent72 Hrs Post-StentNo No AntiplateletAntiplateletChaturvedi S et al Stroke 2001;32:2700-02RM Bersin SCAI Core Curriculum in Carotid Stenting 2005RM Bersin SCAI Core Curriculum in Carotid Stenting 200630-Day Total Stroke in U.S.Carotid Stenting High Risk Registries3.44.04.24.55.65.86.90246810Patients(%)Patients(%)ARCHeR 2ARCHeR 2(ACC 2003)(ACC 2003)SAPPHIRESAPPHIRE(AHA 2002)(AHA 2002)SECuRITYSECuRITY(TCT 2003)(TCT 2003)BEACHBEACH(TCT 2004)(TCT 2004)MAVErICMAVErIC (TCT 2004)(TCT 2004)CREATECREATE(TCT 2004)(TCT 2004)CABERNETCABERNET(TCT 2004)(TCT 2004)RM Bersin SCAI Core Curriculum in Carotid Stenting 2006EVA-3S TrialEVA-3S TrialMas JL et al.N Engl J Med 2006;355:1660-1671Dual Anti-platelet use 82.9%Dual Anti-platelet use 82.9%Symptomatic Carotid Symptomatic Carotid StenosisStenosisRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Guide Catheter TechniqueGuide Catheter TechniqueRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Initial AccessInitial Access?Stroke risk?Placing guide catheter?Telescope 5fr VTK 125cm catheter through 100cm guidecatheter(Headhunter,Hockey Stick,JR4,etc.)?Engage carotid with VTK?Slide guide over VTK and into carotidRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Guiding CathetersCarotid Guiding CathetersRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Guide AlternativesGuide Alternatives?Additional support:?Steerable 0.035”wire(Storq,Magic Torque,SupraCore,etc)or 0.014 buddy wire?For small CCA or ostial plaque:sheathtechniqueRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Sheath Technique with Shaped DilatorSheath Technique with Shaped Dilatoror Diagnostic Catheteror Diagnostic Catheter?Image carotid bifurcation with diagnostic cath?0.035”wire through it and into carotid?Internal carotid lesions:Place wire into external carotidRemove catheterAdvance sheath over wire into common carotidWithdraw wire and dilator?Common carotid lesionsMUST stop equipment short of the lesionRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Sheath with 6F DilatorCarotid Sheath with 6F DilatorRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Sheaths with Shaped DilatorsCarotid Sheaths with Shaped Dilators5 Fr with JB1to Lead Sheath6 Fr with DilatorRM Bersin SCAI Core Curriculum in Carotid Stenting 2006“Set UpSet Up”Angio Angio?Non-subtracted orroadmap?Lateral projection isusually the best?Lesion clearlyvisualized?“Landing zone”forprotection?Dont move tableInternal Carotid StenosisRM Bersin SCAI Core Curriculum in Carotid Stenting 20060.035”wire into external carotid arterySheath TechniqueSheath TechniqueRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Sheath TechniqueSheath TechniqueRM Bersin SCAI Core Curriculum in Carotid Stenting 2006OstialOstial Carotid Carotid StenosisStenosisStop carotid sheath short of lesionStop carotid sheath short of lesionRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Balloon Expandable Balloon Expandable StentStentGuide CatheterGuide CatheterPercuSurge BalloonPercuSurge BalloonOstialOstial Carotid Carotid StenosisStenosisRM Bersin SCAI Core Curriculum in Carotid Stenting 2006OstialOstial Carotid Carotid StenosisStenosisRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Emboli Protection DevicesEmboli Protection DevicesRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Henry et al,J Endovasc Surg,6:321-331,1999Carotid Carotid StentingStentingDistal Protection-OcclusionDistal Protection-OcclusionPercuSurgePercuSurgeRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Carotid StentingStentingDistal Protection FiltersDistal Protection FiltersRMB 4.24.02.JPG2RMB 2.25.00.JPG8RM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Carotid StentingStentingFlow Reversal DevicesFlow Reversal DevicesRM Bersin SCAI Core Curriculum in Carotid Stenting 20063,4,5,6,76-72.9Nitinol filterEv-3Spidern.a.10F sheathn.a.prox.balloonArteriaParodin.a.11F sheathn.a.prox.balloonInvatecMOMA5.5,6.56F2.9Nitinol filterMedtronicInterceptor4.5,5.5,6.5,7.57-83.5-3.7Parachute filterGuidantRX Accunet3,4,5,67-83.7-3.9Parachute filterAbbottEmboShield6.063.2Parachute filterBostonFilterWire EZ4,5,6,7,87-83.3-3.9Parachute filterCordisAngioguard3.0-6.062.8dist.balloonMedtronicGuardWireDiameter(mm)Guidingcath(F)Crossingprofile(F)TypeCompanyDeviceComparison of CarotidProtection DevicesRM Bersin SCAI Core Curriculum in Carotid Stenting 20060%1%2%3%4%5%Unprotected(n=3582 cases)Protected(n=1135cases)Procedural DeathsMajor StrokesMinor Strokes4.7%4.7%3.6%3.6%Wholey MH et al Catheter Cariovasc Interv 2003;60:259-266Carotid Stent ComplicationsCarotid Stent ComplicationsWith and Without Distal ProtectionWith and Without Distal ProtectionRM Bersin SCAI Core Curriculum in Carotid Stenting 2006EVA-3S TrialEVA-3S TrialMas JL et al.N Engl J Med 2006;355:1660-1671Use of Embolic Filters 91.9%Use of Embolic Filters 91.9%30-Day Stroke/Death 7.9%30-Day Stroke/Death 7.9%With Embolic ProtectionWith Embolic Protection30-Day Stroke/Death 25%30-Day Stroke/Death 25%Without Embolic ProtectionWithout Embolic ProtectionSymptomatic Carotid Symptomatic Carotid StenosisStenosisRM Bersin SCAI Core Curriculum in Carotid Stenting 2006FilterWire EZAccunetAngioGuardEPD Wall Apposition in CurvesRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Poor Apposition on BendsPoor Apposition on BendsFilterWireFilterWire EX EXRM Bersin SCAI Core Curriculum in Carotid Stenting 2006CREATE Pivotal:Risk of Stroke&CREATE Pivotal:Risk of Stroke&Duration of Filter DeploymentDuration of Filter DeploymentExtent of Stroke*No CVA 18.8 9.3 minMinor CVA 17.7 7.8 minMajor CVA25.7 16.6 minFilter Deployment Duration*30 min 10.8%*p=0.02*p=0.004RM Bersin SCAI Core Curriculum in Carotid Stenting 2006Slide 0Emboli Protection DevicesEmboli Protection DevicesRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Emboli Protection DevicesEmboli Protection DevicesRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Avoiding Carotid Stent ComplicationsAvoiding Carotid Stent ComplicationsThe Case for Proximal ProtectionThe Case for Proximal ProtectionRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Avoiding Carotid Stent ComplicationsAvoiding Carotid Stent ComplicationsThe Case for Proximal ProtectionThe Case for Proximal ProtectionBalloon Pre-DilateBalloon Pre-Dilate Confirm adequacy of distalprotection 4.0 X 20 or 30 rapid exchangeballoon Observe BP and pulse asbefore-use atropine prn The goal is to make room forstent expansion.Do not overdilate!RM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Stent DevicesCarotid Stent DevicesRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Carotid StentStent Systems SystemsRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Artery DiseaseCarotid Artery DiseaseStent Therapy-Stent Therapy-NitinolNitinol StentsStentsOpen CellOpen CellClosed CellClosed CellRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Artery DiseaseCarotid Artery DiseaseStent Therapy-Open CellStent Therapy-Open CellRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Artery DiseaseCarotid Artery DiseaseStent Therapy-Closed CellStent Therapy-Closed CellRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Stent TechniqueCarotid Stent TechniqueRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Placing and Deploying StentPlacing and Deploying Stent?Watch protection device as youadvance?Beware of stent pushing guide orsheath down?Go just beyond intended landingzone?Ask:what will happen to vesselkink?RM Bersin SCAI Core Curriculum in Carotid Stenting 2006Placing and Deploying StentPlacing and Deploying Stent?Start to deploy?Withdraw to intendedposition?Fully deployBalloon Post-DilateBalloon Post-Dilate Probably the most emboli-prone step Confirm adequacy of distalprotection 5.0 or 6.0 X 20 rapid exchangeballoon Observe BP and pulse asbefore The goal is not 0%residual!RM Bersin SCAI Core Curriculum in Carotid Stenting 2006From Initial Access To Final ResultFrom Initial Access To Final ResultRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Filter Retrieval StepFilter Retrieval Stepor Aspiration if PercuSurge Usedor Aspiration if PercuSurge UsedAspirate embolic debris withExport catheterRM Bersin SCAI Core Curriculum in Carotid Stenting 2006Intracranial CirculationIntracranial Circulation?Mandatory:?New neurologic signs or symptoms?Research requirement?Dont if?Renal insufficiency?Uncomplicated case?AP and lateral?10”field of view,DSARM Bersin SCAI Core Curriculum in Carotid Stenting 2006Carotid Carotid StentingStenting Tips and Tricks Tips and Tricks