Technique Of Carotid Technique Of Carotid Stenting Stenting Decision Making Analysis To Overcome Decision Making Analysis To Overcome Challenges Challenges Subbarao Myla MD FACC Subbarao Myla MD FACC Hoag Memorial Hospital Presbyterian Hoag Memorial Hospital Presbyterian Newport Beach, CA Newport Beach, CA USA USA
Presenter Disclosure Information Name: Subbarao Myla, MD Within the past 12 months, the presenter or their spouse/partner have had the financial interest/arrangement or affiliation with the organization listed below. Company Name: Relationship: • Johnson & Johnson Research Grant/Speaker • Guidant Research Grant/Speaker • Boston Scientific Research Grant/Speaker •Abbott Research Grant/Speaker •Enotex Research Grant/Speaker •EV3 Research Grant/Speaker
Critical Decision Making Critical Decision Making Carotid Access Issues Carotid Access Issues Carotid Filter Issues Carotid Filter Issues Carotid Stent Issues Carotid Stent Issues Neuro Rescue Neuro Rescue
Carotid Access Carotid Access Can I Safely Get There? Can I Safely Get There? – CCA Access CCA Access Can I Safely Get There? Can I Safely Get There? – Distal Protection Device into ICA Distal Protection Device into ICA
Critical Issues Critical Issues Which Carotid Access Technique? Which Carotid Access Technique? – Front Loading Telescopic Technique Front Loading Telescopic Technique – Back Loading Serial Stiffening Technique Back Loading Serial Stiffening Technique – TAD Wire Method TAD Wire Method – Remote Carotid Access Remote Carotid Access
Carotid Access Determinants Carotid Access Determinants Aortic Arch Type Aortic Arch Type CCA/ECA Disease CCA/ECA Disease Carotid Tortuosity Carotid Tortuosity
Arch Types (Myla 1996) Arch Types (Myla 1996) Type III Arch Type II Arch Type I Arch
Aortic Arch Aortic Arch Need to visualize the arch Need to visualize the arch – Assess the Arch Type Assess the Arch Type Type I Type I Type II Type II Type III Type III – Arch Disease Arch Disease Ulceration Ulceration Atheroma Atheroma – Arch Anomalies Arch Anomalies – Ostial Stenosis Ostial Stenosis
Aortic Arch Aortic Arch Need to visualize the arch Need to visualize the arch – Assess the Arch Type Assess the Arch Type Type I Type I Type II Type II Type III Type III – Arch Disease Arch Disease Ulceration Ulceration Atheroma Atheroma – Arch Anomalies Arch Anomalies – Ostial Stenosis Ostial Stenosis
Aortic Arch Aortic Arch Need to visualize the arch Need to visualize the arch – Assess the Arch Type Assess the Arch Type Type I Type I Type II Type II Type III Type III – Arch Disease Arch Disease Ulceration Ulceration Atheroma Atheroma – Arch Anomalies Arch Anomalies – Ostial Stenosis Ostial Stenosis
Aortic Arch Aortic Arch Need to visualize the arch Need to visualize the arch – Assess the Arch Type Assess the Arch Type Type I Type I Type II Type II Type III Type III – Arch Disease Arch Disease Ulceration Ulceration Atheroma Atheroma – Arch Anomalies Arch Anomalies – Ostial Stenosis Ostial Stenosis
Carotid Access Determinants Carotid Access Determinants Aortic Arch Type Aortic Arch Type – Type I Arch Type I Arch Telescopic Method Telescopic Method_Cook Shuttle Select _Cook Shuttle Select – Type II Arch Type II Arch Serial Stiffening Method_SM2 Supracore_Shuttle Serial Stiffening Method_SM2 Supracore_Shuttle – Type III Arch Type III Arch Remote Access_Vitek_8F JCL 3.5 Remote Access_Vitek_8F JCL 3.5
Carotid Access Determinants Carotid Access Determinants CCA/ECA Disease CCA/ECA Disease – Type I Arch Type I Arch Simple Lesion Simple Lesion – TAD Wire method TAD Wire method Complex Lesion Complex Lesion – 0.038 Stiff Angled Glide 0.038 Stiff Angled Glide in CCA method in CCA method – Type II Arch Type II Arch 0.038 Stiff Angled 0.038 Stiff Angled Glide/Nitrex Wire Glide/Nitrex Wire method method – Type III Arch Type III Arch Remote Access with Guide Remote Access with Guide catheter catheter
Carotid Access Determinants Carotid Access Determinants Carotid Tortuosity Carotid Tortuosity – Type I Arch Type I Arch Telescopic access Telescopic access Serial Stiffening Method Serial Stiffening Method – Type II Arch Type II Arch Serial Stiffening Method Serial Stiffening Method Remote Access Remote Access – Type III Arch Type III Arch Avoid Them Avoid Them Direct Carotid Stick Direct Carotid Stick Remote Carotid Access Remote Carotid Access
Critical Issues Critical Issues Should I Choose Guide Catheter or Should I Choose Guide Catheter or Guide Sheath? Guide Sheath? Should I Keep Guide C/S In distal CCA Should I Keep Guide C/S In distal CCA or proximal CCA? or proximal CCA? When do I choose large size Guide When do I choose large size Guide C/S? C/S?
Critical Issues Critical Issues Should I Choose Guide Catheter or Should I Choose Guide Catheter or Guide Sheath? Guide Sheath? – Individual Preference Individual Preference GC more stable allows torque GC more stable allows torque GS smaller size smoother transition (No ledge GS smaller size smoother transition (No ledge effect) effect) – Carotid Tortuosity Carotid Tortuosity GC allows torque GC allows torque – Remote carotid access Remote carotid access GC More stable GC More stable
Critical Issues Critical Issues When do I choose large size Guide C/S? When do I choose large size Guide C/S? – Usual Sizes Usual Sizes Guide Sheath Guide Sheath 6F Larger Size 7F 6F Larger Size 7F Guide Catheter Guide Catheter 8F Larger Size 9F 8F Larger Size 9F – Large Sizes Large Sizes Anticipate Buddy wires Anticipate Buddy wires – Carotid Tortuosity Carotid Tortuosity Beginner Beginner – Avoid air embolism Avoid air embolism – Allow contrast injection for precise device Allow contrast injection for precise device placement placement
Carotid Filter Issues Carotid Filter Issues Should I Pre-dilate Before Filter Should I Pre-dilate Before Filter Placement? Placement? What to do with slow What to do with slow Flow/occlusion in a filter? Flow/occlusion in a filter? – Is this Filled Filter? Is this Filled Filter? – Is this carotid Spasm? Is this carotid Spasm? What is happening at the filter site? What is happening at the filter site? – Is this Spasm, Kink or dissection? Is this Spasm, Kink or dissection? What do to when the retrieval What do to when the retrieval sheath fails to advance? sheath fails to advance? How to Handle a detached filter? How to Handle a detached filter?
Carotid Filter Issues Carotid Filter Issues What to do when filter doesn’t What to do when filter doesn’t Advance? Advance? – Poor guide support Poor guide support – Carotid tortuosity Carotid tortuosity – Severe stenosis Severe stenosis – Large filter Large filter – Sharp entry angle Sharp entry angle – Sharp exit angle Sharp exit angle
Internal Internal Carotid Artery Carotid Artery Sharp Entry angle Sharp Entry angle Sharp Exit angle Sharp Exit angle Distal ICA bends Distal ICA bends Distal ICA kinks Distal ICA kinks Distal ICA loops Distal ICA loops FMD FMD Arteriosclerosis Arteriosclerosis Aneurysm Aneurysm
Internal Internal Carotid Artery Carotid Artery Sharp Entry angle Sharp Entry angle Sharp Exit angle Sharp Exit angle Distal ICA bends Distal ICA bends Distal ICA kinks Distal ICA kinks Distal ICA loops Distal ICA loops FMD FMD Arteriosclerosis Arteriosclerosis Aneurysm Aneurysm
Carotid Filter Issues Carotid Filter Issues What to do when What to do when filter doesn’t filter doesn’t Advance? Advance? – Solutions Solutions Power Guide support Power Guide support Pre-dilatation Pre-dilatation Buddy Wire Buddy Wire Buddy Catheter Buddy Catheter Bare wire/Spyder Bare wire/Spyder Percusurge Percusurge Proximal Protection Proximal Protection
Carotid Filter Issues Carotid Filter Issues Should I Pre-dilate Before Should I Pre-dilate Before Filter placement? Filter placement? – Carotid Tortuosity Carotid Tortuosity Fixed Wire Filters Fixed Wire Filters – Pre-dilate severe stenosis Pre-dilate severe stenosis – Reduces friction during filter Reduces friction during filter travel travel Bare Wire Filters Bare Wire Filters – No need to pre-dilate No need to pre-dilate In situ Wire Filters (Spyder) In situ Wire Filters (Spyder) – No need to pre-dilate No need to pre-dilate
Carotid Filter Issues Carotid Filter Issues Should I Pre-dilate Should I Pre-dilate Before Filter Before Filter placement? placement? – Carotid Lesion Severity Carotid Lesion Severity Pre-dilate for Pre-dilate for subtotal occlusions subtotal occlusions – Segmental Segmental – Long lesions Long lesions – String signs String signs No need to pre-dilate No need to pre-dilate – Short Short – Focal subtotal Focal subtotal occlusions occlusions
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