avoiding and managing complications during cas: lessons ... · cerebral embolism - use appropriate...

Horst Sievert, Ilona Hofmann, Kolja Sievert, Laura Vaskelyte, Sameer Gafoor, Stefan Bertog, Predrag Matić,

Markus Reinartz, Bojan Jovanovic, Iris Grunwald, Nalan Schnelle

CardioVascular Center Frankfurt - CVC,

Frankfurt, Germany

LINC 2019Leipzig, Germany, Jan 22-25, 2019

Avoiding and Managing

Complications During CAS:

Lessons Learned

Physician name Company Relationship

Horst Sievert 4tech Cardio, Abbott, Ablative Solutions, Ancora Heart, Bavaria Medizin TechnologieGmbH, Bioventrix, Boston Scientific, Carag, Cardiac Dimensions, Celonova, Comed B.V., Contego, CVRx, Dinova, Edwards, Endologix, Hemoteq, Lifetech, Maquet Getinge Group, Medtronic, Mitralign, Nuomao Medtech, Mokita, Occlutech, pfm Medical, Recor, Renal Guard, Rox Medical, Terumo, Vascular Dynamics, Venus, Vivasure Medical

Consulting fees,

Travel expenses,

Study honoraria to institution

Disclosures

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

Patient Selection

• General risk factors- Comorbidities - Age

• Morphologic risk factors- Difficult access

• Iliac tortuosity, aortic arch type III , elongated CCA

- Lesion morphology• Thrombus, large plaque

- Morphology of the distal ICA• Elongation, kinking

- Contralateral occlusion, isolated hemishere

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

Medication

• Discontinue drugs inducing bradycardia and hypotension- ß-Blocker, Ca antagonists

• Aspirin + Plavix 1 week before

• Don't treat hypertension during the procedure before the

stent is implanted

• Heparin (5,000-7,500 units or ACT controlled)

• Atropine before balloon inflation

• Catecholamines if needed

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

Complications during access

• Catheter manipulation in the aortic arch is a major source of cerebral embolism- Use appropriate catheters and

techniques

• Avoid air embolism and thromboembolism- Always de-air the sheath after

introducing something

- Always flush the sheath when you have blood inside

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

Strictly avoid

touching the plaque

with the wire

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

Have different EPD available and consider:

• Proximal and distal tortuosity

• Distal landing zone

• Thrombus and plaque load

• External carotid artery open?

• Distal CCA diseased?

Avoid malposition of filters

Verify position!!

• With prox occlusion: Avoid flow from the ECA into

the ICA

The Suprathyreoid artery has to be occluded otherwise there is zero protection!

In our experience, the use of prox. protection in all patients has dramatically reduced the 30 day stroke rate

• 207 consecutive patients regardless of anatomy

- No periprocedural stroke

- One stroke after discharge due to stent thrombosis

• 30 day stroke rate < 0.5%

First 124 patients: Hornung M et al: http://www.ncbi.nlm.nih.gov/pubmed/25042420; Sievert H et al, CRT 2016

If embolism occurs:

Be prepared for intracranial rescue

Recanalization using microcathetersMiddle cerebral artery branch

occluded

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

Avoid stiff stents in elongated vessels

Stent Selection

Double layered stents prevent complications

Catheter Cardiovasc Interv. 2018;91:751–757

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

The first device that combines an embolic protection filter and balloon

40 micron pore size allows micro-embolic capture

Filter size can be adjusted to suit each patient’s unique anatomy

Integrated Filter:• 40 Micron pores• Baseline closed• Sheathless

Angioplasty Balloon

Catheter

New Concept: Paladin Double filtrationIntegrated Embolic Protection (IEP)TM

Using PALADIN, clinical outcome was superior compared to almost all other carotid stenting studies

• Paladin Study:

106 patients

No procedural Stroke

1 unrelated stroke

Low stroke rate

References available for individual study resultsProspective multi-center studies with >100 patients

6.7

8.3

7.2

5.4 5.2

3.9

6.1

10

6.8

2.9 2.8

1.5

2.7

5.2

3.5 3.3

0.90

2

4

6

8

10

12

30-Day MAE defined as death, stroke or MI

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

Complications can occur at each step

• Patient selection• Center and operator selection• Medication• Getting access• Crossing the lesion• Embolic protection• Pre-dilatation• Stent selection and implantation• Post-dilatation• Retrieval of embolic protection device• Post stent management

Post stent

• Keep BP low to prevent hyperperfusion syndrome

• If BP is too low + symptoms

- give pressors

• Bradycardia

- give atropin

• Aspirin & Plavix for 4 weeks

In Conclusion• The complication rate of CAS is much lower today

• All the old randomized trials …

• … as well as the ongoing randomized trials …

• … are outdated!

Thank you!

HorstSievertMD@aol.com

Horst Sievert, Ilona Hofmann, Kolja Sievert, Laura Vaskelyte, Sameer Gafoor, Stefan Bertog, Predrag Matić,

Markus Reinartz, Bojan Jovanovic, Iris Grunwald, Nalan Schnelle

CardioVascular Center Frankfurt - CVC,

Frankfurt, Germany

LINC 2019Leipzig, Germany, Jan 22-25, 2019

Avoiding and Managing

Complications During CAS:

Lessons Learned