Angioplasty and Stenting of the Carotid and Supra Aortic Trunks

Cover......Page 1
Angioplasty and Stenting of the Carotid and Supra-aortic Trunks......Page 2
Contents......Page 4
Contributors......Page 10
Preface......Page 16
References......Page 18
Foreword: vascular surgery at the start of the twenty-first century......Page 19
PART I  Carotid artery stenosis: natural history, histopathology......Page 22
Asymptomatic carotid bruit......Page 24
Carotid bruits and risk of cardiovascular disease......Page 25
Conclusion......Page 26
References......Page 27
Mechanisms of acute coronary syndromes......Page 28
General features of carotid atherosclerosis......Page 29
Carotid versus coronary disease: differences in plaque morphology......Page 31
Risk factors contributing to symptomatic carotid disease......Page 32
Correlation of risk factors to plaque morphology......Page 33
Endarterectomy and stroke......Page 34
Recurrent carotid disease......Page 35
Conclusion......Page 36
References......Page 37
PART II  Supra-aortic arteries: anatomy, radiological anatomy......Page 38
General anatomy of supra-aortic vessels......Page 40
Vertebral arteries......Page 41
Intracranial arterial anastomosis (circle of Willis)......Page 42
Pathophysiology of supra-aortic vessels......Page 43
Other pathological lesions of the carotid arteries......Page 44
References......Page 45
Left subclavian artery......Page 46
Vertebral artery and vertebrobasilar system......Page 47
Vertebrobasilar system......Page 48
Common carotid artery and bifurcation......Page 49
External carotid artery......Page 51
Internal carotid artery......Page 52
References......Page 53
Anterior communicating artery......Page 54
Posterior communicating artery......Page 56
ICA-ECA anastomosis......Page 57
References......Page 58
PART III  Imaging techniques......Page 60
Introduction......Page 62
Geometric effects in clinical Wallstent cases......Page 63
Model experiments: Wallstent versus segmented Nitinol stent......Page 64
References......Page 66
Ultrasound......Page 68
Angiography......Page 70
Computed tomography and computed tomographic angiography......Page 75
Magnetic resonance imaging and magnetic resonance angiography......Page 78
Conclusion......Page 81
References......Page 82
Computed tomographic and magnetic resonance imaging brain scans......Page 84
Computed tomographic angiography......Page 85
Magnetic resonance angiography......Page 88
References......Page 90
Peak systolic velocity ratio......Page 92
Diameter reduction......Page 93
Role of plaque morphology as an independent risk of cerebral events......Page 94
Transcranial Doppler......Page 95
Before the procedure (Figs 9.6 and 9.7)......Page 96
During the procedure......Page 98
Follow-up......Page 99
References......Page 100
Introduction......Page 104
Applications of transcranial Doppler during carotid endarterectomy......Page 105
Conclusion......Page 106
References......Page 107
Transcranial Doppler technique......Page 110
Microembolic profile during carotid artery stenting......Page 111
Assessment of antiemboli devices......Page 112
References......Page 114
The European or ‘E’ method......Page 116
Echo-Doppler criteria......Page 117
Peak systolic velocity ratio......Page 118
Ratio of the peak systolic velocity of the internal carotid artery to the end-diastolic volume of the common carotid artery......Page 119
References......Page 120
The need for B-mode image normalization: description of the method......Page 122
Natural history studies......Page 126
Future perspectives: the ACSRS study......Page 127
References......Page 128
Introduction......Page 130
Results......Page 131
Homogeneous plaques......Page 134
Discussion and conclusion......Page 135
References......Page 136
Embolic risk with carotid artery stenting......Page 138
Reduction of the embolic burden on the brain......Page 139
Grey-scale median......Page 140
Rationale......Page 143
Final results......Page 144
References......Page 145
Technical aspects......Page 148
Discussion......Page 150
References......Page 154
PART IV  Clinical assessment......Page 156
Preprocedure neuropsychological evaluation......Page 158
Postprocedure neuropsychological evaluation......Page 159
References......Page 160
Carotid ultrasound......Page 162
Medical history......Page 163
Chest X-ray......Page 164
Radionuclide imaging: thallium-201 scanning......Page 165
Positron emission tomography......Page 166
Computed tomographic and magnetic resonance coronary angiography......Page 167
References......Page 168
PART V  Carotid artery stenosis: surgery......Page 172
Symptomatic carotid artery disease......Page 174
Surgical technique......Page 175
Nerve injury and wound complications......Page 176
Carotid angioplasty and stenting: current status......Page 177
Conclusion......Page 178
References......Page 179
Randomized trials for symptomatic carotid artery stenoses......Page 182
North American Symptomatic Carotid Endarterectomy Trial I......Page 183
Veterans Affairs Asymptomatic Trial......Page 184
Discussion......Page 185
References......Page 186
Limitations of standard therapy for carotid disease......Page 188
Technique of carotid stenting......Page 190
References......Page 192
PART VI  Clinical trials......Page 194
Symptomatic carotid stenosis......Page 196
Carotid angioplasty and stenting......Page 197
Carotid angioplasty and stenting for NASCET- and ACAS-eligible patients......Page 198
Standard procedure......Page 199
Results......Page 200
CREST: a randomized clinical trial contrasting carotid angioplasty and stenting with carotid endarterectomy......Page 201
Conclusion......Page 202
References......Page 203
Is carotid artery stenting ready for mainstream use?......Page 204
The trials......Page 205
Current techniques for carotid stenting......Page 207
Managing endovascular complications......Page 210
Conclusion......Page 212
References......Page 213
Results of CAVATAS......Page 214
The learning curve......Page 218
CAVATAS-2......Page 219
Protocol for the International Carotid Stenting Study......Page 220
References......Page 221
Patients and methods......Page 222
Technical details of the intervention......Page 223
Discussion......Page 224
References......Page 226
Participating investigators......Page 227
PART VII  Indications for carotid angioplasty and stenting......Page 228
26  Candidates for carotid revascularization......Page 230
References......Page 231
Introduction......Page 232
Imaging......Page 233
The Investigational Device Exemption protocol......Page 234
Discussion......Page 235
References......Page 236
Diagnosis of asymptomatic carotid artery stenosis......Page 238
Natural history: progression of asymptomatic carotid artery stenosis......Page 239
Females and asymptomatic carotid surgery......Page 240
Stenting of the stenosed carotid arteries......Page 241
Summary......Page 242
Effect of dietary factors on raised homocysteine in stroke......Page 243
References......Page 244
Predictors of periprocedural strokes......Page 248
Definitions......Page 250
Risk stratification......Page 251
References......Page 252
Imaging......Page 254
Stent procedure......Page 255
Conclusion......Page 259
References......Page 260
31  Management of concomitant coronary and carotid disease......Page 262
References......Page 264
Incidence......Page 266
Inflammation and restenosis......Page 267
Treatment......Page 268
Endovascular treatment......Page 269
Drug-eluting stents......Page 270
References......Page 271
Preprocedure medication......Page 274
Technique during the procedure......Page 275
Results......Page 277
References......Page 279
34  Extracranial carotid aneurysm; interventional treatment......Page 282
References......Page 287
Mechanisms of stroke after carotid endarterectomy......Page 288
Carotid stenting......Page 289
Emergency carotid stenting experience......Page 290
Carotid stenting versus surgical re-exploration......Page 292
References......Page 295
PART VIII  Technique devices......Page 298
Introduction......Page 300
New techniques......Page 301
Femoral access (Figs 36.1 and 36.2)......Page 302
Direct internal carotid artery puncture (Fig. 36.4)......Page 305
Angioplasty and stenting with predilatation......Page 306
Pharmacological regimen and periprocedural surveillance......Page 307
Follow-up......Page 308
References......Page 309
Option 1......Page 312
Recommended technique......Page 313
Arch difficulties......Page 314
Ostial stenosis of the common carotid artery/brachiocephalic trunk......Page 315
Distal common carotid artery stenosis......Page 316
Tortuous internal carotid artery......Page 317
Brachial approach......Page 318
Direct carotid puncture......Page 319
Future developments......Page 320
References......Page 321
Anatomical considerations......Page 322
Carotid artery access......Page 323
Catheterization of the carotid arteries......Page 324
Guiding sheath placement......Page 325
Solving difficult access problems......Page 326
References......Page 327
Selective cerebral catheters......Page 328
0.035 inch extra-support wires......Page 331
Angioplasty wires......Page 332
Occlusive balloons......Page 333
Filters......Page 334
Flow-reversal devices......Page 337
Angioplasty balloons......Page 338
Tubular, balloon-expandable stents......Page 339
Self-expanding wire mesh......Page 340
Nitinol self-expanding stents......Page 341
References......Page 342
Generation of embolic particles......Page 344
The stent......Page 345
Cerebral protection techniques......Page 346
Occlusion of the internal carotid artery......Page 347
Description of the protection device (Figs 40.1 and 40.2)......Page 348
Protected carotid angioplasty and stenting technique (Fig 40.3)......Page 349
Disadvantages and limitations of this technique......Page 350
The Henry-Amor-Frid-Rüfenacht (HAFR) device......Page 352
Disadvantages and limitations of filters......Page 353
Seatbelt and airbag technique......Page 358
Discussion: is cerebral protection efficient?......Page 360
References......Page 362
Creation of emboli......Page 366
The procedure: materials in use......Page 367
Advantages of distal occlusion balloons......Page 368
Description......Page 369
Technique......Page 370
Technique......Page 371
Description......Page 372
Technique......Page 374
Description......Page 375
Limitations......Page 376
Description......Page 377
Other devices......Page 378
Parodi antiembolization system......Page 379
Description......Page 380
Limitations......Page 381
References......Page 383
Preparation of a human carotid plaque......Page 386
Performance of various stents......Page 387
Risk of embolization......Page 388
Description......Page 389
Animal model......Page 390
References......Page 391
Failure to deploy the distal protection device......Page 394
Abrupt change in stiffness......Page 395
Problems related to capture efficiency......Page 396
With filter protection......Page 397
Spasm in the distal internal carotid artery......Page 399
Conclusion......Page 400
References......Page 401
The simplified cerebral protection strategy......Page 402
Patient inclusion criteria......Page 403
Description of the procedure......Page 404
Results......Page 405
Complications related to the use of cerebral protection devices......Page 406
Discussion......Page 408
References......Page 410
The standard and acceptable risks......Page 412
Gender......Page 413
General anatomical  considerations......Page 414
Kinks, coils and tortuosity of the internal carotid artery......Page 415
Calcification......Page 416
Embolization protection devices......Page 417
Proximal balloon occlusion and flow reversal......Page 418
Intravenous antiplatelet agents......Page 419
Heparin......Page 420
Seizure......Page 421
Contrast encephalopathy......Page 422
References......Page 423
46  Avoidance and management of complications in cervical carotid revascularization......Page 426
References......Page 433
Single-step carotid access......Page 434
Stent deployment......Page 435
Stent selection......Page 437
Selection of stent length and positioning......Page 438
Other performance and safety aspects......Page 439
References......Page 441
48  Carotid angioplasty and stenting indications for covered stents......Page 442
References......Page 446
Plastic-warping alloys......Page 448
Description or shape-memory alloys: Nitinol......Page 449
Comparison between the cobalt-alloy and the Nitinol braided stents......Page 450
Braided stents......Page 451
Conclusion......Page 452
References......Page 453
PART IX  Medical treatment......Page 454
50  Prevention of ischaemic stroke......Page 456
References......Page 457
Cerebrovascular disease in India......Page 458
Magnetic resonance angiography......Page 459
Carotid angioplasty and stenting......Page 460
References......Page 461
Moderation of alcohol consumption......Page 464
Treatment of hyperlipidaemia......Page 465
Ticlopidine......Page 466
References......Page 467
Definition and classification......Page 470
Pathological-anatomical picture of ischaemic vascular cerebral disease......Page 471
Obesity......Page 472
Carotid artery disease......Page 473
Carotid angioplasty (percutaneous transluminal angioplasty)......Page 474
Dipyridamole......Page 475
References......Page 476
PART X  Clinical results......Page 478
Patient population......Page 480
Statistical analysis......Page 481
Late follow-up......Page 482
Discussion......Page 483
Study limitations......Page 485
References......Page 486
Procedure and technique......Page 488
Immediate procedural complications......Page 490
Postprocedure complications......Page 491
Discussion......Page 493
References......Page 495
Development of carotid stenting......Page 498
Development of carotid cerebral protection......Page 499
Results of carotid stenting and cerebral protection......Page 501
Status of clinical trials......Page 503
Conclusion......Page 504
References......Page 505
Description of the protection device......Page 506
Protected carotid angioplasty and stenting technique......Page 507
Follow-up......Page 508
Lesion characteristics......Page 509
Immediate technical success......Page 510
Collected debris......Page 511
Thirty-day complications......Page 512
Discussion......Page 513
Limitations of the technique......Page 514
Conclusion......Page 515
References......Page 516
Filter design......Page 518
Experience with the NeuroShield filter......Page 519
Thirty-day outcomes......Page 520
Clinical findings......Page 521
References......Page 522
Overview......Page 524
Personal experience......Page 526
Summary......Page 527
Trap neurovascular filtration system......Page 528
Results......Page 529
Spider embolic protection device......Page 530
Recovery phase......Page 531
Conclusion......Page 532
Introduction......Page 534
Procedure......Page 535
References......Page 536
Materials and methods......Page 538
Procedure......Page 539
Procedural success in positioning and removal of Trap filter......Page 540
Discussion......Page 541
References......Page 542
Background......Page 544
Flow-reversal technique for cerebral protection......Page 545
Procedural caveats......Page 547
Clinical results......Page 548
Discussion......Page 549
References......Page 550
Introduction......Page 552
Theron balloon......Page 553
Clinical evaluation of distal balloon occlusion devices......Page 554
AngioGuard XP system......Page 556
BSc FilterWire EX......Page 557
Clinical evaluation of filter-based devices......Page 558
MOMA......Page 559
References......Page 560
Materials and methods......Page 562
Results......Page 564
Embolic protection......Page 565
References......Page 566
Why stenting?......Page 568
Why a registry?......Page 569
References......Page 570
PART Xl  Complications: intracranial endovascular therapy......Page 572
Procedure and technique......Page 574
Management of neurological complications......Page 575
Procedural complications......Page 576
Discussion......Page 580
References......Page 582
Clinical trials......Page 584
Imaging requirements for a stroke centre......Page 585
References......Page 589
Intracranial atherosclerosis: definition of the problem and epidemiology......Page 590
Surgical management of symptomatic intracranial stenosis......Page 591
Evaluation of the procedure......Page 592
General operative technique......Page 593
Severity of stenosis......Page 595
Unintended stent dislodgement......Page 596
Postoperative morbidity and follow-up......Page 597
Discussion......Page 598
References......Page 599
Dynamics of intracranial arterial stenoses......Page 602
Perfusion failure......Page 603
Occlusion of small penetrating arteries at the site of stenosis......Page 605
Patients with intracranial carotid siphon stenosis......Page 606
Patients with stenosis of the middle cerebral artery......Page 607
Symptomatic patients with intracranial atherosclerotic stenosis......Page 608
Conventional surgical revascularization with craniotomy......Page 609
Stent-assisted angioplasty......Page 610
Premedication......Page 611
Guide catheter......Page 612
Lesion navigation and angioplasty......Page 613
Postprocedural management......Page 615
Follow-up......Page 616
References......Page 617
Aneurysms......Page 622
Arterial stenosis......Page 623
References......Page 625
Introduction......Page 626
Stroke......Page 627
In-hospital management......Page 629
Stroke classification......Page 630
Neuroimaging......Page 631
Ischaemic stroke......Page 635
The first 03.00 hours after onset......Page 638
Management 03.00–08.00 hours after onset......Page 639
Endovascular treatment......Page 641
Anticoagulation......Page 647
Cerebral infarction with mass effect......Page 648
Depressive hemicraniectomy......Page 649
Haemorrhagic stroke......Page 651
Discharged patients......Page 656
References......Page 658
PART XII  Other supra-aortic occlusive arterial diseases: endovascular treatment......Page 664
Atherosclerotic disease: stent-assisted angioplasty......Page 666
Stent-assisted aneurysm management......Page 668
Stent placement for acute stroke......Page 669
Periprocedural medical management......Page 671
Future directions......Page 672
References......Page 673
Clinical signs......Page 676
Techniques of angioplasty......Page 677
Femoral approach......Page 678
Stenting......Page 680
Immediate technical results......Page 681
Discussion......Page 683
References......Page 690
General considerations......Page 694
Indications for vertebral angioplasty......Page 695
Techniques......Page 696
Angiographic results......Page 698
Discussion......Page 699
References......Page 701
Technical aspects......Page 704
Angioplasty......Page 705
Results......Page 706
References......Page 707
Index......Page 710