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