Carotid Artery Stenting: Procedural Complications Aman B. Patel, MD Massachusetts General Hospital Harvard Medical School
Disclosure Statement of Financial Interest Within the past 12 months, I have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company • • Consulting Fees/Honoraria Covidien • Penumbra
Outline • Pre- EPD • Stent Deployment • Post Stent Deployment 3
Embolic Stroke • Catheterization • Crossing the Lesion • Angioplasty – pre or post • Placement of Stent • Retrieval of EPD
Embolic Stroke Quantification of emboli Transcranial Doppler Procedure CEA CAS Number of 52 ± 64 202 ± 119 hits Crawley F, Clifton A, Buckenham T, et al.. Stroke 1997 5
Protection Devices Stroke and death rate within 30 days = 1.8% with protection compared with 5.5% without protection ( P< 0.001). Mainly due to a decrease in occurrence of minor strokes (3.7% vs 0.5%; P< 0.001) and major strokes (1.1% vs 0.3%; P< 0.05), whereas death rates were almost identical (0.8%; 20.3, P= 0.6). 6
Protection Device Carotid Artery Stenting Impact of NeuroProtection – Global Registry 6 Mino nor s stroke Majo jor S Stroke 5 Death De 4 2.8 .86 3 2 1.1 1. 1.6 .61 1 0.7 .72 0.8 .82 0.4 .45 0 Unprotected Un Pr Protect cted N = 6,688 cases ses 4,005 cases es 7
Protection Device Limitations • Large profile • Abrupt change in stiffness • Capture efficiency – Pore size (>100uM) – Incomplete occlusion – Filter retrieval • Dissection 8
Embolic Stroke - Management VS
Embolic Protection Device - Issues Vessel Occlusion • Embolic protection device can lead to slow flow, hypoperfusion injury, thrombosis • 9% in a single center retrospective review. Casserly, I; et al: JACC 2005 Volume 46, Issue 8, 2005, 1466 – 1472
Vasospasm Navigating the vessels: Hemodynamically significant spasm in 3-5 % of cases Tex Heart Inst J. 2010; 37(2): 226 – 229. Embolic Protection Device
Vasospasm - Management • Removal of device and time • IA Nitro 100 microgram aliquouts • IA Verapamil 10 mg aliquouts • IA Nicardipine • Look for vessel injury/dissection, distal emboli
Stent Deployment Complications 13
Bradycardia and Hypotension • Rates range from 10-42% • Associated with: older age, female, MI, CAD, stenosis at carotid bulb • Drug Intervention required in ~ 50% sypmtomatic patients AJNR November 2008 29: 1942-1947
Managing Bradycardia Hypotension • Arterial Line • Communication with Anesthesia team • Atropine/Glycopyrrolate at time of angioplasty • Volume versus pressors at time of treatment • Monitoring 6-12 hours following procedure 15
Stent Deployment In stent thrombosis: 0.5-5% in early devices, 0.04-2% with modern anti-platelet regimen. Sabine Steiner-Böker et al. AJNR 2004;25:1411-1413
Stent Thrombosis • Acute • IA IIB/IIIA inhibitors followed by IV drip • Mechanical thrombectomy with aspiration • Delayed • ? Thrombosis vs restenosis • ? Platelet aggregation vs thrombus • IA treatments with IIB/IIIA or tPA or aspiration • IV heparin to stabilize the clot Sabine Steiner-Böker et al. AJNR 2004;25:1411-1413
Other stent issues • Vasospasm • Placement in tortuosity • Significant vessel size mismatch • Tx if needed with IA vasodilators • Dissection • Can be treated medically in most instances • If flow limiting consider placement of additional stent 18
Post-Deployment: Hyperperfusion Hyperperfusion syndrome and Hemorrhage Rare (0.67%) Journal of the American College of Cardiology . 2004;43(9):1596 – 1601.
Post-Deployment: Hyperperfusion • Increase in perfusion of 100% compared to baseline • Clinical signs: Somnolence, Headache, Seizure, Signs of increased ICP, aphasia, weakness. • Within 12 hours to days following procedure • 10-24% of cases of syndrome • 0.6-0.8% of cases with ICH • Risks • Diabetes, Age, recent contralateral procedure, incomplete COW, high grade stenosis, post-op hypertension J. Vasc Surg 2009 Apr;49(4):1060-8.
Post Stent Deployment • Inability to recapture EPD • Most instances related to inability to pass retrieval catheter through stent • Head rotation, extension, manual displacement of carotid with external force • Consider 4F or 5F catheter with angled tip to retrieve device. Angled tip allows for rotating around turns
Post Stent Deployment Femoral Pseudoaneurysm: approximately 3% of patients Jpn. J. Vasc. Surg., 13: 1-6, 2004
Delayed: Stent Fracture • 11 of 312 at 1 year follow-up (3.4%) • Associated with Calcification and vessel angulation • Correlated with restenosis following stent J. Vasc Surg. 2010 Jun;51(6):1397-405. 23
Conclusions • Overall Safe Procedure • Acute risks still less than that of open surgery • Risks Decrease with increased use and Technology improvements
Citations 1.Abou-Chebl A, Yadav JS, Reginelli JP, Bajzer C, Bhatt D, Krieger DW. Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: Risk factors, prevention, and treatment. J Am Coll Cardiol . 2004;43:1596-1601 2.Brott TG, Howard G, Roubin GS, Meschia JF, Mackey A, Brooks W, et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med . 2016;374:1021-1031 3.Casserly IP, Abou-Chebl A, Fathi RB, Lee DS, Saw J, Exaire JE, et al. Slow-flow phenomenon during carotid artery intervention with embolic protection devices: Predictors and clinical outcome. J Am Coll Cardiol . 2005;46:1466-1472 4.Coppi G, Moratto R, Veronesi J, Nicolosi E, Silingardi R. Carotid artery stent fracture identification and clinical relevance. J Vasc Surg . 2010;51:1397-1405 5.Lin PH, Zhou W, Kougias P, El Sayed HF, Barshes NR, Huynh TT. Factors associated with hypotension and bradycardia after carotid angioplasty and stenting. J Vasc Surg . 2007;46:846-853; discussion 853-844 6.Moulakakis KG, Mylonas SN, Sfyroeras GS, Andrikopoulos V. Hyperperfusion syndrome after carotid revascularization. J Vasc Surg . 2009;49:1060-1068 7.Reimers B, Corvaja N, Moshiri S, Sacca S, Albiero R, Di Mario C, et al. Cerebral protection with filter devices during carotid artery stenting. Circulation . 2001;104:12-15 8.Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med . 2016;374:1011-1020 9.Steiner-Boker S, Cejna M, Nasel C, Minar E, Kopp CW. Successful revascularization of acute carotid stent thrombosis by facilitated thrombolysis. AJNR Am J Neuroradiol . 2004;25:1411-1413 10.Taha MM, Sakaida H, Asakura F, Maeda M, Toma N, Sano T, et al. Access site complications with carotid angioplasty and stenting. Surg Neurol . 2007;68:431-437 11.Vijayvergiya R, Otaal PS, Bagga S, Modi M. Symptomatic carotid vasospasm caused by a distal-protection device during stent angioplasty of the right internal carotid artery. Tex Heart Inst J . 2010;37:226-229 12.Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med . 2004;351:1493-1501
Thanks Jpn. J. Vasc. Surg., 13: 1-6, 2004
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