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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3871_Библиотеки_им_академика_М_И_Перельмана
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Chapter 5: Intra-arterial treatment of ischemic stroke
http://internalmedicinebook.com
Figure 5.8 Native imaging of the cervical region
demonstrates the ease with which the modern guide
catheters, in this case the Neuron MAX 0.088", traverse
tortuous anatomy (in this case a 360° loop) to allow
distal purchase. Care must be taken, however, during
multiple passes. It is easy for the guide catheter to
move or lose position, and then subsequent
(inadvertent) advancement may oppose the catheter
tip against the vessel wall, resulting in dissection.
arch anatomy or proximal large vessel stenosis/tortuosity, or occluded femoral arteries.
Typically a 6 French sheath may be placed, and the procedure can be performed with a
6 French guide such as a soft-tip Envoy or Neuron catheter (Penumbra, USA). If the
5 French system is considered, there are still various choices of guides such as the Navien™
058, Envoy, Chaperon, DAC 057, Neuron™ 053, and 5 MAX catheter.
One additional word of caution in utilizing these newer-generation guide catheters in
difficult vasculature: Although these catheters are excellent for improving distal purchase,
and even can be advanced across 360° loops (Figure 5.8) the catheter tip will at times abut
directly against the vessel wall in this type of configuration. Care should be taken to place
the catheter in a straight segment either well proximal to, or well beyond such a loop, so that
any guide catheter movement will not dissect the vessel at this point.
Unsuccessful thrombectomy
Even after difficult catheterization is accomplished, thrombectomy itself may be unsuccessful. Inadequate time of aspiration is one reason for aspiration thrombectomy failure.
Aspiration of 5–15 minutes is reasonable for the Penumbra system, depending on catheter
size. Upsizing the device where possible is a reasonable next step. The 5 MAX and ACE
device, as stated, is intended for terminal ICA occlusions and large MCA (M1), and possibly
even basilar artery occlusions, while the 4 MAX and 3 MAX are designed more for distal
occlusions (e.g. M2 and beyond). The 3 MAX specifically is longer than the other catheters,
with the specific intent to reach more distal occlusions. Guide catheter and reperfusion
catheter compatibility should be checked. It may also be usef ul to abandon standard
convention here, and commence aspiration thrombectomy from the mid-clot position (to
ensure that the appropriate target area is covered).
79
Chapter 5: Intra-arterial treatment of ischemic stroke
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ABCD
EF G
Figure 5.9 A 66-year-old gentleman with NIHSS of 19, no improvement noted with IV a lteplase. CT angiogram
showed occluded left ICA and MCA. Patient was intubated since could not cooperate during cerebral
angiogram. This confirmed occlusion of left ICA (A) with minimal trickle of contrast in carotid bulb, best seen in
lateral view (B). Microwire could be advanced, therefore 4 French vertebral artery catheter was placed near
origin and exchange length microwire was advanced intracranially into left ICA for support. There is no
intracranial filling noted in AP or lateral vi ew (C, D, E, F). A 4 mm Spider distal embolic protection device was
advanced into distal left ICA (G) and after performing angioplasty with 5 mm × 30 mm monorail balloon, an
Xact stent measuring 9– 7 mm × 40 mm was deployed successfully (H). Guide catheter run confirmed
terminal left ICA occlusion involving whole supraclinoid segment (I). Microcatheter injection demonstrates
thrombus in left MCA extending f rom M1 to M2 segments (J). Solitaire stent-retriever device was used with
distal aspiration through 5 MAX c atheter, and complete recanalization was achieved with visualization of left
ophthalmic artery, near fetal origin of left posterior cerebral artery, left A CA and TICI 2b filling of left MCA
(K, L, M). Follow-up guide catheter injection demonstrates residual 35% stenosis in the stent (N, O). DWI
sequence of MRI (P) on following day demon strated scattere d left MCA distribution acute i nfarct involving the
left temporal, frontal, and parietal lobes and left basal ganglia. Patient was discharged to acute rehabilitation
and had mild hemiparesis with dysarthria.
In the case of stent-retrievers, there may be variable strategies, for instance making
another pass with the same retriever or using a new stent-retriever (same or different
company); using direct aspiration with an intermediate catheter such as Neuron 4 MAX or
5 MAX; or using intra-arterial thrombolytics. There is no established dose regimen for
IA recombinant tPA, although 22 mg is the maximum dose in the Interventional Management of Stroke 3 trial protocol. In clinical practice, typical IA tPA doses used are much less
than this
22
.
80
Chapter 5: Intra-arterial treatment of ischemic stroke
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IJ K
H
LM NO
P
Figure 5.9 (cont.)
Tandem stenosis/occlusions
A tandem occlusion is a rare presentation of acute stroke that involves occlusion of the
proximal cervical ICA at the bifurcation with an intracranial MCA occlusion, although
the distal lesion may also involve the ACA territory. The underlying pathophysiology
involves either atherosclerotic disease or a dissection of the proximal vasculature leading
to complete occlusion and an embolus causing a distal tandem occlusion. Two
approaches exist for the treatment of tandem occlusions, treating either the proximal
occlusion or the distal occlusion first; th ere is no consensus o n which approach is more
efficacious, but we prefer treating the proximal occlusion first followed by distal
occlusion (Figure 5.9).
The concerns for angioplasty and stent placement in acute setting includes the procedure's technical feasibility (e.g. the success of stent insertion under severe stenosis or
occlusion and the distal embolization caused by manipulation of highly vulnerable plaque),
81
Chapter 5: Intra-arterial treatment of ischemic stroke
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safety (e.g. the potential risk of developing acute in-stent stenosis due to the lack of
antiplatelet premedication), related complications (e.g. cerebral hyperperfusion syndrome
(CHS)) and effectiveness for improving patients’ neurological deficits and long-term
follow-up. It may be difficult to cross the lesion with a distal protection device, and thus
a proximal method of protection (e.g. flow reversal or balloon occlusion) may have to be
employed. However, with a downstream MCA occlusion, the added step of utilizing a
protection device may not confer much additional benefit. In a study of 22 cases that had
emergent carotid artery angioplasty and stenting, but had not received dual antiplatelet
medications if they h ad already received IV alteplase, none of these patients developed
in-stent thrombosis. In a nother study of 23 patients, it was concluded that primary
stenting of the extracranial carotid artery combined with intracranial mechanical thrombectomy can be an effective treatment for tandem occlusions, can be performed with a
high rate of technical success, and can achieve good clinical outcomes in selected patients.
However, the incidence of symptomatic intracranial hemorrhage (SICH) may be higher
than in other patient populations and may be associated with the use of Abciximab and
advanced patient age. Therefore, aggressive antiplatelet use should be avoided in such
23
. W e are careful about monitoring blood pressure closely and control it to keep it
cases
less than 120 mmHg if we achieved good recanalization distally; otherwise, keep between
120 and 140 mmHg.
Conclusions
Interventional stroke therapy presents one of the most difficult procedures in the neuroendovascular realm. The “need for speed”, unfavorable anatomy, recalcitrant clot, and
critically ill patients all interact to create a complex treatment scenario. Adequate planning,
from medication agents to specific materials, can all help to minimize procedural risks and
technical failures.
References
1. Furlan A, Higashida R, Wechsler L, et al.
Intra-arterial prourokinase for acute
ischemic stroke. The PROACT II study: a
randomized controlled trial. Prolyse in
Acute Cerebral Thromboembolism. JAMA
1999;282:2003–11.
2. Smith WS, Sung G, Saver J, et al.
Mechanical thrombectomy for acute
ischemic stroke: final results of the Multi
MERCI trial. Stroke 2008;39:1205–12.
3. PPST Investigators. The Penumbra pivotal
stroke trial: safety and effectiveness of a
new generation of mechanical devices for
clot removal in intracranial large vessel
occlusive disease. Stroke 2009;40:2761–8.
4. Berkhemer OA, Fransen PS, Beumer D,
et al. A randomized trial of intraarterial
treatment for acute ischemic stroke. N Engl
J Med 2015;372:11–20.
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5. Campbell BC, Mitchell PJ, Kleinig TJ, et al.
Endovascular therapy for ischemic stroke
with perfusion-imaging selection. N Engl
J Med 2015;372:1009–18.
6. Goyal M, Demchuk AM, Menon BK, et al.
Randomized assessment of rapid
endovascular treatment of ischemic stroke.
N Engl J Med 2015;372:1019–30.
7. Saver JL, Goyal M, Bonafe A, et al. Solitaire
with the Intention for Thrombectomy as
Primary Endovascular Treatment for Acute
Ischemic Stroke (SWIFT PRIME) trial:
protocol for a randomized, controlled,
multicenter study comparing the Solitaire
revascularization device with IV tPA with
IV tPA alone in acute ischemic stroke. Int
J Stroke 2015;10:439–48.
8. del Zoppo GJ, Higashida RT, Furlan AJ,
et al. PROACT: a phase II randomized trial
of recombinant pro-urokinase by direct
Chapter 5: Intra-arterial treatment of ischemic stroke
http://internalmedicinebook.com
arterial delivery in acute middle cerebral
artery stroke. PROACT Investigators.
Prolyse in Acute Cerebral
Thromboembolism. Stroke 1998;29:4–11.
9. Adams HP, Jr., Effron MB, Torner J, et al.
Emergency administration of Abciximab
for treatment of patients with acute
ischemic stroke: results of an international
phase III trial: Abciximab in Emergency
Treatment of Stroke Trial (AbESTT-II).
Stroke 2008;39:87–99.
10. Broderick JP, Palesch YY, Demchuk AM,
et al. Endovascular therapy after
intravenous t-PA versus t-PA alone for
stroke. N Engl J Med 2013;368:893–903.
11. Hussein HM, Georgiadis AL, Vazquez G,
et al. Occurrence and predictors of futile
recanalization following endovascular
treatment among patients with acute
ischemic stroke: a multicenter study. AJNR
Am J Neuroradiol 2010;31:454–8.
12. Natarajan SK, Karmon Y, Snyder KV, et al.
Prospective acute ischemic stroke
outcomes after endovascular therapy: a
real-world experience. World Neurosurg
2010;74:455–64.
13. Janjua N, El-Gengaihy A, Pile-Spellman J,
Qureshi AI. Late endovascular
revascularization in acute ischemic stroke
based on clinical-diffusion mismatch.
AJNR Am J Neuroradiol 2009;30:1024–7.
14. Levi M, Eerenberg E, Kamphuisen PW.
Bleeding risk and reversal strategies for old
and new anticoagulants and antiplatelet
agents. J Thromb Haemost 2011;9:1705–12.
15. Cooper ES, Bracey AW, Horvath AE, et al.
Practice parameter for the use of freshfrozen plasma, cryoprecipitate, and
platelets. Fresh-Frozen Plasma,
Cryoprecipitate, and Platelets
Administration Practice Guidelines
Development Task Force of the College of
American Pathologists. JAMA
1994;271:777–81.
16. Yoon W, Seo JJ, Kim JK, et al. Contrast
enhancement and contrast extravasation on
computed tomography after intra-arterial
thrombolysis in patients with acute
ischemic stroke. Stroke 2004;35:876–81.
17. Qureshi AI, Hussein HM, Janjua N, HarrisLane P, Ezzeddine MA. Postprocedure
intravenous eptifibatide following intraarterial reteplase in patients with acute
ischemic stroke. J Neuroimaging
2008;18:50–5.
18. Qureshi AI, Harris-Lane P, Kirmani JF,
et al
. Intra-arterial reteplase and
intravenous
acute ischemic stroke: an open-label,
dose-ranging, phase I study. Neurosurgery
2006;59:789–96; discussion 96–7.
19. Flint AC, Cullen SP, Faigeles BS, Rao VA.
Predicting long-term outcome after
endovascular stroke treatment: the totaled
health risks in vascular events score. AJNR
Am J Neuroradiol 2010;31:1192–6.
20. Kwon HJ, Chueh JY, Puri AS, Koh HS.
Early detachment of the Solitaire stent
during thrombectomy retrieval: an in vitro
investigation. J Neurointerv Surg
2015;7:114–17.
21. Kurre W, Vorlaender K, Aguilar-Perez M,
et al. Frequency and relevance of anterior
cerebral artery embolism caused by
mechanical thrombectomy of middle
cerebral artery occlusion. AJNR Am
J Neuroradiol 2013;34:1606–11.
22. Khatri P, Hill MD, Palesch YY, et al.
Methodology of the Interventional
Management of Stroke III Trial. Int J Stroke
2008;3:130–7.
23. Heck DV, Brown MD. Carotid stenting and
intracranial thrombectomy for treatment of
acute stroke due to tandem occlusions with
aggressive antiplatelet therapy may be
associated with a high incidence of
intracranial hemorrhage. J Neurointerv
Surg 2015;7:170–5.
Abciximab in patients with
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Chapter
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Carotid angioplasty and stenting:
complication avoidance
6
and management
Ramachandra P. Tummala
Introduction
From the ongoing debate and trials addressing the indications for and relative efficacy of
carotid angioplasty and stenting (CAS) versus carotid endarterectomy (CEA) in stroke
prevention, a key message emerges: both CAS and CEA are durable treatments when carried
out successfully, with the bulk of strokes occurring periprocedurally in head-to-head trials
Meticulous attention to complication avoidance and management during CAS is fundamental to its overall success in stroke prophylaxis. While CAS is generally straightforward, certain
patients continue to pose technical challenges during various stages of the procedure.
Table 6.1 summarizes the major randomized clinical trials regarding CAS. The following
techniques are the result of experience with these technical difficulties and complications.
The purpose of the present chapter is not to discuss the merits or disadvantages of carotid
stenting, nor is it to compare carotid stenting with CEA. The risks of endovascular therapy
must always be weighed against the risks of surgery or medical therapy in the individual
patient. It is with the anticipation that an increased number of complex cases will be referred
for endovascular therapy that the described techniques may be germane. Some of these
technical “pearls” are already used at other centers; undoubtedly many more are unknown
to our group but already used by other experienced interventionalists. The following
techniques have allowed the expansion of the endovascular limits of treating carotid artery
disease, and we believe they are useful for complication avoidance and management.
1
.
Standard technique for carotid angioplasty and stenting
The approach for routine CAS is fairly standardized with minor institutional variations
(Figure 6.1). We perform almost all of these procedures through a transfemoral approach.
Through a groin sheath, we advance a 5 French diagnostic catheter (often a Simmons
2 configuration catheter) into the mid common carotid artery (CCA) and obtain a diagnostic angiogram, including baseline intracranial runs. Under normal conditions, we
advance a stiff exchange length wire into the distal external carotid artery (ECA) and
exchange the diagnostic catheter and groin sheath for a long introducer sheath (often a
90 cm long 6 French Cook Shuttle, Cook Incorporated, Bloomington, IN). Alternatively
with tortuous anatomy, various other guide catheters can be used. After positioning the tip
of the introducer or guide catheter (for simplicity we will refer to these devices as guide
Complications of Neuroendovascular Procedures and Bailout Techniques, ed. Rakesh Khatri,
Gustavo J. Rodriguez, Jean Raymond and Adnan I. Qureshi. Published by Cambridge University Press.
© Cambridge University Press 2016.
84
Table 6.1 Summary of randomized clinical trials of carotid angioplasty and stenting (CAS) versus carotid endarterectomy (CAE)
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CAVATAS
8
Wallstent
9
SAPPHIRE
10
EVA-3S
11
SPACE
12
CREST
Year published 2001 2001 2004 2006 2006 2010
Period of
enrollment
May 1992 to
July 1997
January
1997 to June
August 2000 to July
2002
September 2000 to
September 2005
March 2001 to
March 2006
December
2000 through July 2008
1999
Country Europe,
Australia,
and Canada
Inclusion criteria Presence of
clinically
important
stenosis
determined
by local
criteria
United States United States France Germany,
Austria, and
Switzerland
Symptomatic
ICA stenosis
60%
Symptomatic ICA
stenosis 50%,
asymptomatic ICA
stenosis 80%, and
1 high-risk surgical
criteria
Symptomatic ICA
stenosis 60%
Symptomatic
ICA stenosis
50% according
to NASCET
criteria or 70%
according to
ECST criteria
United States and
Canada
Symptomatic ICA
stenosis 50% on
angiography, 70%
on US, on CTA or MRA
if the stenosis on US
was 50–69%.
In 2005 extended to
asymptomatic
stenosis of 60% or
angiography, 70%
US, or 80% on CTA
or MRA if the stenosis
on US was 50–69%.
Determination
of eligibility
Noninvasive
techniques
Angiography Doppler ultrasound
or angiography
Conventional
angiography or Doppler
plus MRA
Duplex
ultrasound or
angiography
Angiography, CTA,
MRA, US
or
angiography
13
85
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Table 6.1 (cont.)
Requirements
for
interventionalists
CAVATAS
Not
specified
8
Wallstent
Not specified Required to submit
9
SAPPHIRE
10
experience and
results
11
EVA-3S
Performed at least
12 carotid stenting
procedures or at least
35 stent placement
procedures in the supraaortic trunks, of which at
least 5 were in the carotid
artery
12
SPACE
Performed at
least
25 successful
consecutive
percutaneous
carotid
angioplasties or
stent
procedures
Primary end
point
30-day rate
of disabling
stroke or
death
Ipsilateral
stroke or
procedurerelated or
vascular
death at 1
year
A composite of
death, stroke, or MI
within 30 days after
the intervention or
death or ipsilateral
stroke between
31 days and 1 year
Any stroke or death
within 30 days after
treatment
Ipsilateral
ischemic stroke
or death from
randomization
to 30 days after
procedure
Intervention CEA CAS CEA CAS CEA CAS CEA CAS CEA CAS CEA CAS
Patients
246 240 112 107 151 159 259 261 565 567 1240 1262
treated, n
Mean age, y 67 67 70 67 72 72 70 69 68 68 69 69
Symptomatic 91% 88% 100% 100% 29% 30% 100% 100% 100% 100% 53% 53%
Men 70% 69% 62% 66% 68% 68% 78% 72% 72% 72% 66% 64%
CAD 37% 39% 74% 85% 24% 21%
Angina 29% 37%
13
CREST
More than
12 procedures per year,
with complication and
death rate <3% for
asymptomatic and
<5% among
symptomatic patients
The primary end point
was the composite of
any stroke, myocardial
infarction, or death
during the
periprocedural period
or ipsilateral stroke
within 4 years after
randomization.
MI 17% 19% 28% 19% 13% 11%
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Previous CEA 24% 29%
CHF 4% 7% 18% 18%
History of stroke 39% 37% 37% 40% 24% 27% 20% 13% 43% 44%
History of TIA 26% 25% 62% 65% 32% 31% 23% 25% 31% 30%
Hypertension 58% 53% 82% 69% 85% 86% 72% 73% 76% 75% 86% 86%
Diabetes mellitus 13% 14% 28% 34% 27% 26% 26% 22% 28% 26% 30% 31%
Hyperlipidemia 32% 34% 58% 55% 79% 80% 56% 58% 86% 83%
Stenosis (mean) 77% 75% 75% 76%
Contralateral
8% 10% 1% 5% 3% 2%
occlusion
Technical success 89% 97% 89% 93%
Primary end
5.9% 6.4% 3.6%12.1% 20.1% 12% 3.9% 9.6% 6.3% 6.8% 6.8% 7.2%
point rates
30-day combined
9.9% 10% 4.5% 12.1% 5.4% 4.8% 3.9% 9.6% 6.5% 7.7% 4.5% 5.2%
periprocedural
complication rate
CAD: coronary artery disease; CHF, congestive heart failure; ECST, European Carotid Surgery Trial; CTA: computed tomography angiography; MI: myocardial infarction;
MRA: magnetic resonance angiography, NASCET, North American Symptomatic Carotid Endarterectomy Trial; TIA, transient ischemic attack; US: ultrasound.
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Chapter 6: Carotid angioplasty and stenting
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Table 6.2 Common devices in a typical carotid stent placement procedure
Closed cell carotid stent Wallstent and NexStent (Boston Scientific Natick, MA)
Xact (Abbott Vascular, IL)
Open cell carotid stent Acculink (Abbott Vascular, IL)
Precise (Cordis, NJ) Exponent (Medtronic, MN)
Protégé (Covidien, CA)
Zilver 518® RX (Cook Medical, IN)
Distal embolic protection device Angioguard (Cordis, NJ)
Emboshield (Abbott Vascular, IL)
Accunet (Abbott Vascular, IL)
Spider (Covidien, CA)
Gore Embolic Filter (Gore, DE)
FilterWire EZ (Boston Scientific, MA)
FiberNet (Medtronic, MN)
Proximal embolization protection
devices
Gore Flow Reversal System (Gore, AZ)
Mo.Ma (Medtronic, MN)
BCA
Figure 6.1 A 68-year-old
gentleman with symptomatic
right ICA stenosis. A: AP view
demonstrates right ICA stenosis
measuring about 60%. A 6 French
Cook shuttle guide is also
visualized. B: A 7 mm to 10 mm ×
40 mm Acculink stent deployed
across stenosis. Distal embolic
protection device is also
visualized in distal cervical ICA.
C: Post angioplasty, improved
lumen with residual stenosis of
about 25%.
devices) in the distal CCA, the patient is anticoagulated with intravenous heparin to achieve
an activated clotting time of greater than 250 seconds. Using roadmap guidance, we cross
the stenotic lesion with a distal embolic protection device that is deployed in a straight
segment of the distal cervical internal carotid artery (ICA). We only perform pre-stenting
angioplasty (predilatation) if the lesion is too stenotic to cross with the stent delivery
system. After stent deployment, a post-stenting angioplasty (postdilatation) is performed.
If the patient’s baseline heart rate is less than 80, we administer 0.2 mg of intravenous
glycopyrrholate or 0.4 mg atropine, prior to angioplasty. Final angiographic images including intracranial runs are reviewed prior to retrieval of the distal embolic protection device.
At the conclusion of the procedure, we use most of the various commercially available
devices for percutaneous closure if the common femoral artery access is suitable. Routine
carotid stenting can be performed relatively quickly with minimal blood loss. Usual devices
in routine practice are provided in Table 6.2.
88
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