How I approach patients with both proximal common carotid disease & carotid bifurcation disease Peter A. Schneider, MD Kaiser Hospital and Hawaii Permanente Medical Group Honolulu, Hawaii
DISCLOSURE Peter A. Schneider Enter patients in studies sponsored by: Gore, Cordis, Medtronic, Silk Road, Bard, NIH, Limflow Modest royalty: Cook Scientific Advisory Board (non-compensated): Abbott, Medtronic, Boston Scientific, CSI Chief Medical Officer: Intact Vascular, Cagent National co-PI: Roadster 2, Scaffold, Confidence, In.Pact
Patterns of Disease XX XX Distance between Dangerous for Multiple options the lesions CEA and CAS available Moore and Schneider. Simin Vasc Surg 2011;24:2
Combined Proximal Common Carotid and Bifurcation Disease § Options - Hybrid Procedure: CEA with intraoperative retrograde stent - All endo: Proximal CCA stent and bifurcation stent - All open: Inflow bypass and CEA - <2% of cases
xxx xxx xxx Needle puncture at inferior Wire directed into aspect of arteriotomy descending aorta Make sure the patient is well anticoagulated. Size the CCA and evaluate the arch with CTA. Beware long lesions-consider inflow bypass instead.
xxx xxx Clamp CCA Balloon expandable stent Lengthen arteriotomy proximal common CEA carotid artery Do the inflow first. Flush it well. Shunt as indicated.
Retrograde contrast injection through a severe arch lesion 5F transfemoral catheter in the arch during stent placement Size the stent by CTA
Balloon expandable stent placed with slight extension into the arch.
Results of Hybrid Carotid Procedures A meta-analysis of combined endarterectomy and proximal balloon angioplasty for tandem disease of the arch vessels and carotid bifurcation Giorgos S. Sfyroeras, MD, PhD, Christos Karathanos, MD, George A. Antoniou, MD, Vassileios 133 patients in 13 studies Prroximal lesion: CCA in 85 , Innominate in 48 Technical success: 97% 79 stents, 50 PTA’s 30 day: stroke 1.5%, mortality 0.7% Follow-up 12-36 months Proximal recurrent stenosis: 7 of 50 (14%) PTA’s, 3 of 79 stents (4%) Sfyroeras et al. J Vasc Surg 2011;54:534
Combined Proximal Common Carotid and Bifurcation Disease Results of Hybrid Carotid Procedures Proximal lesion location Author Patients Age Symptomatic Symptoms (patients) Innominate artery CCA Sidhu 6 2 72-74 1 Stroke (1) 0 2 Levien 2 44 60.4 � 8.1 44 TIA (19), amaurosis fugax (9), TIA and amaurosis 24 20 fugax (5), retinal embolus (3), stable stroke (5), nonhemispheric symptoms (3) Sullivan 7 5 nr nr � 0 5 Macierewitz 8 8 70 (64-78) 8 TIA (6), nondisabling stroke (1), amaurosis fugax (1) 1 7 Arko 9 6 74.7 (63-78) 2 Cerebral ischemia (2) 1 5 Greko 3 16 70 (56-80) 8 TIA (2), nonfocal cerebral symptoms (6) 6 10 Lutz 10 2 nr nr nr 2 0 Allie 11 34 68 � 9.6 nr nr 11 23 Payne 12 8 64 � 10.8 7 TIA (3), amaurosis fugax (3), nondisabling stroke (1) 2 6 Peterson 13 3 nr nr nr 1 2 Basan 14 1 71 1 Ocular ischemic syndrome (1) 0 1 Nakahara 15 1 75 0 — 0 1 Karathanos 16 3 54, 62, 78 2 Stroke (1), TIA (1) 0 3 Angioplasty/ Author stenting Sequence Shunt Sidhu 6 2/0 CEA/angioplasty No Levien 2 43/0 CEA/angioplasty Selectively Sullivan 7 0/5 nr nr Macierewitz 8 0/8 Stenting/CEA Yes Arko 9 0/6 Stenting/CEA Yes Greko 3 0/14 Stenting/CEA Yes Lutz 10 0/2 Stenting/CEA nr Allie 11 0/33 Stenting/CEA Selectively Payne 12 5/3 Stenting/CEA Yes Peterson 13 0/3 Stenting/CEA nr Basan 14 0/1 CEA/stenting nr Sfyroeras et al. J Vasc Surg 2011;54:534 Nakahara 15 0/1 nr nr Karathanos 16 0/3 CEA/stenting Selectively
��� �������������������������������������������������� �������������������������������������������������� ��� �������������������������������������������������� ��� �������������������������������������������������� ��� Combined Proximal Common Carotid and Bifurcation Disease Combined with Eversion Endarterectomy Italian Study-Rome-7 patients: no stroke or death Serbian study-18 patients: no stroke or death Illumenati et al. Int J Surg 2018;52:329 Radak et al. Ann Vasc Surg 2017;44:368
Combined Proximal Common Carotid and Bifurcation Disease Advantage of Cervical Block A B 350 40 38 300 Duration of cross-clamping [min] 36 Duration of operation [min] 34 250 32 200 30 28 150 26 24 100 22 50 20 GA CB GA CB Fig. 2. Patientsundergoingsynchronouscarotidendarterectomyandretrogradeendovascular treatmentunderCBshowed a significant reduction of operation (A) and cross-clamping time (B) when compared to patients with GA; * P < 0.05. Munich: 17 patients randomized to cervical block or general anesthesia Heyn et al. Ann Vasc Surg 2016;34:193
Combined Proximal Common Carotid and Bifurcation Disease Results of Hybrid Carotid Procedures Retrograde stenting of proximal lesions with carotid endarterectomy increases risk 30 day stroke and death 9% Clouse et al. J Vasc Surg 2016;63:1517
Combined Proximal Common Carotid and Bifurcation Disease Results of Hybrid Carotid Procedures Retrograde stenting of proximal lesions with carotid endarterectomy increases risk 23 patients over 11 years, 8 were symptomatic Bifurcation disease treated first: 21 of 23 (91%) Patch: 87% Dissection at stent site: 3 (13%)-2 required more stents, one stroke-death Clouse et al. J Vasc Surg 2016;63:1517
All Endovascular Option xxx xxx Exchange wire Guidewire in the ECA PTA of CCA To support sheath Balloon on the way in to create space for the sheath Moore and Schneider. Simin Vasc Surg 2011;24:2
xxx xxx xxx Wire in ECA Advance sheath Carotid stent CCA stent Withdraw sheath Place filter Remove filter Balloon on the way in Stent on the way out
Increased Risk with Additional Stents During CAS Caution Against Treating Diffuse Lesions § Risk factor for poor outcomes with CAS § Excluded from all carotid stent trials § Need to use a second stent - NSQIP-6.4% MAE when single stent placed, 19.2% when multiple stents placed (OR 7.7, strongest predictor) § Lesion length, Sequential lesions - CREST-Increased risk for CAS (lesion >13mm OR=3.4, sequential lesions OR=3.6) § Lesion that extends beyond that which can be treated with a single stent is typically contraindicated by IFU Bennett et al. J Vasc Surg 2017;66:1093 Moore et al. J Vasc Surg 2016;63:851
62 year old woman left CEA 10 years ago, left carotid-subclavian bypass 6 years ago. Now with symptoms of global hypoperfusion Angioplasty CCA lesion on the way in and stent on the way out
Tandem Lesion Options § Hybrid: Re-do endarterectomy and retrograde CCA stent § All open: options limited. Inflow? § All endo: Stent CCA with balloon expandable stent, proceed with bifurcation stent - Minimize occlusion time - No protection during CCA stent
Filter Sheath Carotid-subclavian bypass
Balloon-expandable stent Angioplasty CCA lesion on the way in and stent on the way out Take out the protection device before backing up sheath
Both proximal common carotid & bifurcation disease Conclusion § Small percentage of cases, but challenging when they present. § Several options for treatment. § Hybrid procedure: CEA plus proximal CCA stent appears to be safe, but with important caveats. - Beware diffuse disease. - CTA for stent sizing and arch assessment. - Place a catheter in the arch. - Fix inflow first.
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