direct carotid access for acute stroke intervention€¦ · 5 or 6 fr sheath to internal carotid...
TRANSCRIPT
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Direct Carotid Access for Acute Stroke Intervention
Mark Wholey M.D. FAHA,FSIR, FSCAI
Omer Goktekin M.D.FACC,FESC
Mehnet Cilingiroglu M.D. FAHA,FSCAI
Dogu Kilic M.D FACC,FESC
Shadyside UPMC; ,Bezmialem VakifUniversity ,Istanbul, Turkey
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Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
• Grant/Research Support• Consulting Fees/Honoraria
• Major Stock Shareholder/Equity
• Royalty Income• Ownership/Founder/PST• Intellectual Property Rights
• Other Financial Benefit
• Company Names• Northwind, Setigone,
Medtronic• Boston Scientific,
St. Jude, Setigone,AccessClosure
• Medtronic• Northwind, Setigone, • Filter Wire, Wholey
Wire,
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0 Hrs 15 Min
Begin
Procedur
e
Reach
the ClotComplete
Procedure
30 Min
Begin
Procedure
0 Hrs 0.5 to 1 Hrs 1.5 to 2.0 Hrs
Reach
the Clot
Complete
Procedure
A NEED FOR SPEED MATCH STEMI
*
Current
Tech
Future Tech
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Access at C-5 and pass5 or 6 fr sheath to Internal carotid
Alll interventional procedures are done through the sheath
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Puncture with 21g
needle at C5 level
Position 10 cm 6fr
sheath
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p
21 g needle at C5
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Remove wire, filter to internal carotid followed by pre dil and stent
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ELIMINATE THE COMPLEX AORTIC ARCH
AND IT’S RISK OF STROKE
IMPROVED PROCEDURE TIME . .
IN THE CAROTID CHOICE TRIAL 18% OF STROKES CAME FROM AORTIC ARCH
What have we learned
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DENSELY CALCIFIC VULNERABLE
PLAQUE IN THE AORTIC ARCH
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Shower Emboli
DWI Embolic stroke
from atherosclerotic
Arch following
carotid intervention
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Best managed
by trans carotid
access-
OCTOGENARIAN TYPE 3 ARCH
EMBOLIC SOURCE
Vulnerable plaque
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PROBLEMS OF THE AORTIC ARCH
Complexities of the aortic arc are
responsible for almost all technical
failures
Ideal TroubleMore
Trouble
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ADVANTAGES of TRANS CAROTID
• SPEED
• MCA /IC only 10, 12 cm distance from sheath
Less contrast media
• Thrombectomy and Aspiration Devices are areonly 30 cm length
• Improved torque control
• Improved aspiration(
• Percutaneous closure
• Disadvantage Radiation
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CASE PRESENTATION
36 year old female
Lengthy history of dilated cardiomyopathy
Pt is on coumadin with an INR of 2.37
Initially admitted to vascular surgery with episode of
acute lower extremity ischemis secondary to an
embolic event
During prep for the peripheral embolic event pt had sudden onset of acute right-sided weakness
Neurological exam demonstrated right-sided
hemiparesis and right-sided hermianovpsia
Speech difficulty with slight motor aphasia and NIH score: 18
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DIFFUSION
MRI
Early ischemic changes
occurring in left lenticulostriate and
periventricular site region
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LEFT MCA
M1 occlusion is
demonstrated on the TOF –
MRA images
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Ultrasound for
localization at C 5 site
10 cm 6 fr SHEATH in position
At the common carotid
and passed to the internal carotid
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5FR ASPIRATION CATH AND
THROMBECTOMY DEVICE SHORTENED
TO -30CM
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ASPIRATION 5 FR CATHETER CONNECT TO ASPIRE
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TOTAL OCCLUSION Lt. M 1 DISTAL TO LENTICULO STRIATES
Collaterals are intact
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WHISPER WIRE 014
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TREVO IN CLOT POSITION AT M 1 AND PROXIMAL M 2
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Solitaire with clot removed
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I
Post Recanalize with Aspire aspiration and thrombectomy
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ASPERATION, THROMBECTOMY,
PERCUTAIEOUS CLOSURE 30’ ,
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ASPERATION, THROMBECTOMY,
PERCUTAIEOUS CLOSURE 30’ ,
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PROGRESSIVE TIMING OF ENTIRE
PROCEDURE
1300•Stroke Onset
1320•Neurologic Exam
1330•Imaging Exam
1400•Direct Carotid Puncture
1415•Device Aspiration & Thrombectomy
1445•Successful Reperfusion & Percutaneous Closure
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THE BALLOONWIRE
29
Novel "balloon on stick" system whereby a weeping balloon is
mounted directly on the distal end of 0.014 designed guidewire
3-4F aspiration catheter
2.1F or 2.7F microcatheter
2.5 ID mm blocked artery 2-2.5mm OD x 2cm long, compliant weeping
balloon
Lytics weeping into thrombus
0.010” or 0.014” modified guidewire
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THE STENTWIRE
30
Novel system whereby a novel stentriever is mounted directly
on the distal end of a triever designed 0.014 wire
Different sizes
• cut through the clots more effectively yet still be atraumatic to the vessel
• provide much larger resistive cross sectional area so that the clot may be removed more easily
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Conclusion
• Mechanical aspiration and thrombectomy from a trans carotid access may be a useful addition to the endovascular treatment for acute stroke
• 30 cm shortened devices are more efficient
Avoids the aortic arch
• Reduced procedure time and percutaneous closure
• Will require further evaluation and ultimately RCT f
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BACKGROUND Despite all current controversies, CAS has excellent
and preferential indication for some symptomatic and asymptomatic patients
Cervical puncture was the routine access for carotid angiography before the diffusion of the Seldingertechnique
The femoral access remains the first choice
The cervical access is not to compete with the femoral access but allows to enlarge CAS possibilities avoiding surgical conversion
It must be learned by vascular surgeons facing difficult accesses
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Percutaneous puncture
The patient's neck is draped like for
surgery and the C arm is placed under
the operating table in a profile view.
The needle is advanced about
2 finger's breadth from the
clavicle, guided on the
arterial pulse
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TRANS CAROTID
INTERVENTION FOR
ACUTE ISCHEMIC STROKE
THE ISTANBUL STROKE TRIAL
Mark Wholey MD,,Omer Goktekin MD,
Mehmet Cilinglroglu MD; Bezmialem
Vaklf, University , Istanbbul, Turkey .
UPMC Shadyside, Pittsburgh.Pa
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HOW TO DO IT
Percutaneous puncture is safer with the use of preclosing device : "Starclose" system from Abbott
General anesthesia is more comfortable for both patients and surgeons ; allowing to focus only on the procedure
A short cut down (2 cm) for reluctant surgeons is acceptable and allow patient discharge at Day 2
Low dose of Heparin (2000 iu) and its reversal5 or 6 F short introducer in CCA
Placement of PCD and stenting is easier by this way
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Kastrup New DWI lesions in elderly : 85% vs 47% --p< .05
(JVS 2008):
Total sample
N=214
Normal arch
N=189
Arch anomalies
N=25p
Technical failure (26) 12% (20) 10.5% (6) 24% 0.005
Neurological
complications(14) 6.5% (9) 4.7% (5) 20% 0.026
Benefits of avoiding arch anomalies
1. Ulcerated lesions is an independent predictor of
any new ipsilateral DWI lesion.
2. Severe aortic arch calcification is a predictor of
new DWI lesions outside the territory treated
Faggioli(EJVS 2007)
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ADVANTAGES Quick procedure
Lower dose of contrast
No arch manipulation
No risk of contralateral or vertebral embolisation
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CONTROL MEDICAL TECHNOLOGY 38
The Aspire Aspiration catheter