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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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260
What type of catheter
is used for treatment
(balloon, stenting)?
6 Fr (sometimes 7 Fr) guide
catheter (e.g., Envoy by Codman
Neurovascular or Shuttle by Cook)
What types of devices
are used for cerebral
protection (embolic
protection devices, or
EPDs)?
Collapsible filters mounted on
0.014in. guidewires and deployed past
the stenosis:
For example, Accunet, Emboshield
BareWire, FilterWire EX, Angioguard
RX, and Spider FX
Temporary balloon occlusion devices
to occlude the common and external
carotid to prevent antegrade or
retrograde flow into the ICA:
For example, Mo.MA Ultra Device
(Medtronic)
What can be used if the
lesion is too small to
cross for a stent device?
Predilation with a small
(3–4mm×20mm or smaller)
noncompliant PTA balloon or a low-
profile cerebral angioplasty balloon
like Gateway (Stryker Neurovascular)
or Maverick (Boston Scientific Corp.)
What type of balloon
can be used to dilate the
stent?
4.0–7.0mm×20mm noncompliant
PTA balloon (diameter matching
that of the normal artery distal to the
target lesion)
What types of stents are
generally used for CAS
of the ICA and why?
Self-expandable stents, due to superior
crush resistance/ability to regain shape
when deformed:
Important due to mobility of the
neck
Where should balloon-
expandable stents be
used and why?
Common carotid artery ostial lesions:
Mobility is limited by thoracic cage
(no crushing).
It allows for more precise
placement.
How should stents be
sized?
Oversized by 1–2mm above diameter
of vessel in the landing zones
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What kind of stents
should be used if there
is a large discrepancy
between the proximal
and distal landing zone
diameters?
Tapered stents
General Step by Step
What components of a
neurological exam should be
completed on the patient pre-
procedurally?
NIHSS, modified Rankin scale,
and Barthel index of ADLs
What can help reduce the risk
of stroke intraprocedurally in
CAS?
Use of EPD (IIa, C) when the
risk of vascular injury from such
a device is low
What medications should be
held pre-procedurally, and
why?
Beta-blockers– already
potential for bradycardia during
manipulation near the carotid
bulb
Metformin (for 24 prior and
48hours after) (due to contrast
use)
What medications should
be started prior to the
procedure?
Dual-antiplatelet therapy:
Clopidogrel (Plavix) 75mg
daily
Aspirin (ASA) 81–325mg daily
How long pre-procedurally
should these medicines be
started?
Elective cases: 5days prior
Emergent cases (within 72hours
of stroke):
Loading dose of Plavix 300mg
PO 3–4hours prior
Loading dose of ASA 650mg
PO or PR 3–4hours
(continued)
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In addition to standard
hemodynamic monitoring,
what type of monitoring is
recommended during CAS,
especially with lesions near
the bifurcation?
Arterial line, for more sensitive
continuous blood pressure
monitoring
How should
anticoagulation be managed
intraprocedurally?
Option 1: Unfractionated
heparin with target ACT of 250–
300seconds
50–70IU/kg loading dose IV,
then titrate
Option 2: Direct thrombin
inhibitors (especially in patients
with HIT)
Argatroban:
15–30 ug/kg/min infusion
with 350 ug/kg bolus followed
by 25ug/kg/min infusion
Bivalirudin:
0.75mg/kg bolus followed
by infusion at 1.75mg/kg/h for
4hours, all IV.
ACT should be checked
5min after bolus (give
additional 0.3mg/kg bolus if
needed at this time).
What medication class can
be used if in-stent clot forms
during the procedure, and
how are they used?
Glycoprotein IIb/IIIa inhibitors
(e.g., eptifibatide (Integrilin) and
abciximab (ReoPro)).
Ensure baseline ACT
<200seconds prior to
administration to reduce risk of
intracranial hemorrhage.
What medicine can be given
to reverse effects of heparin
activity?
Protamine
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How can intraprocedural
bradycardia be managed?
Glycopyrrolate (0.2–0.4mg IV):
Can also be given
prophylactically in lesions near
the bulb to prevent bradycardia
Atropine (0.6–1.0mg)
Dopamine (rarely used)
What medications can help
manage intraprocedural
vasospasm?
Nicardipine, intra-arterial (IA)
Verapamil IA
What IV fluid is best to
manage intraoperative
hypotension and why?
Albumin helps improve cerebral
microcirculation independent of
B P.
Where is access usually
obtained in cases of CAS?
Common femoral artery
(preferred). Radial, brachial,
axillary, or direct carotid
punctures are also used, less
often.
What is the first step after
obtaining access?
Diagnostic angiography (four
vessels)
What are key points to assess
during angiography?
Collateral blood supply via
external carotids, posterior
circulation
Potentially dangerous
anastomoses to the ICA from the
external/vertebrobasilar system
Circle of Willis and intracranial
collaterals
Lesion length, degree of stenosis,
and regional anatomy (landing
zone, relation to bulb, tortuosity,
ulceration, thrombus, amount of
calcifications)
What should be attached to
the guide catheter after four-
vessel angiography and prior
to attempts at crossing an
ICA lesion?
Pressurized bag of heparinized
saline (1 drop/second continuous)
(continued)
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What should be done after
accessing the carotid artery
with the guide catheter?
Cross the lesion using a 0.014in.
wire, and deploy a cerebral
protection device, followed by
angiography of the CCA.
What if the lesion is too small
to cross for a stent device?
Predilate with PTA balloon or
low-profile cerebral angioplasty
balloon.
What are ideal landing zone
dimensions for the stent?
5–10mm on either side of plaque
What should be assessed after
stent placement?
Angiography to evaluate for
residual stenosis, significant if
over 10–15%
What should be done if there
is significant residual stenosis
after stent placement?
Balloon dilation
What should be assessed on
final angiogram after stent
placement and removal of
EPD?
Vasospasm
Dissection
Distal emboli
When is it most crucial to
monitor the patient for
bradycardia?
Anytime there is balloon dilation
or other manipulation about the
carotid bulb
How should tortuous carotid
arteries with stenosis be
approached?
Use two shorter, overlapping
stents to avoid straightening
the artery with a longer stent
and creating pseudo-occlusion/
kinking
For how long after the
procedure should antiplatelet
therapy be continued?
Dual-antiplatelet therapy with
aspirin (81–325mg qd) and
clopidogrel (75mg qd) should
be continued for a minimum of
30days after procedure (I, C).
Aspirin is usually continued
indefinitely.
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How should patients be
managed post-procedurally?
Overnight observation
Vitals and neuro exam hourly
Bed rest until morning
General post-procedural
considerations:
Hydration.
Restart diet.
Remove Foley catheter, if
placed.
DVT prophylaxis.
How should the patient be
clinically examined after
CAS?
Clinical neurological examination
for 24hours after CAS (I, C)
How should the patient be
followed post-procedurally?
Noninvasive imaging of the
extracranial arteries is reasonable
at 1month, 6months, and
annually after revascularization
to assess patency and exclude
development of new or
contralateral lesions (IIa, C):
Usually with Doppler, but can
use CTA/MRA if anatomic
location is too superior for
Doppler
Can extend surveillance time
period once stable over an
extended period.
Can terminate surveillance if
patient no longer a candidate for
re-intervention.
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Complications
What are possible acute
and intraprocedural
complications in CAS?
General arteriographic procedure
complications:
Allergic reaction to contrast
Puncture site trauma/injury
including hematoma and
pseudoaneurysm
Retroperitoneal hematoma (in
cases of femoral access)
Arterial rupture
Arterial dissection
Stroke from distal embolization
Vagal symptoms including
bradycardia and hypotension
How can arterial
hypotension be managed?
Hydration, with pressor support as
needed
How can hemodynamically
significant arterial
dissection be managed?
Immediate stenting, or stop the
procedure and manage medically:
Heparin bridge to Coumadin,
Coumadin for 6months
How can acute
thromboembolism be
managed?
Intra-arterial abciximab or
eptifibatide or tPA
Thrombectomy with stent retriever
Aspiration thrombectomy
Ancillary treatments like colloid
infusion/induction of arterial
hypertension
How can neck hematoma
due to venous or arterial
rupture be managed?
If minor, reverse heparinization
with protamine, usually self-
containing.
If major:
Occlude vessel with balloon
catheter.
Reconstructive methods like
emergent covered stent.
Permanent endovascular
occlusion of the entire carotid
with coils should be considered.
Consider emergency surgery.
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What patients are at
highest risk for venous/
arterial rupture?
Patients with history of prior
CEA, patients with previous neck
irradiation and stricture, and
steroid-dependent patients
How can reperfusion brain
edema be managed?
Mannitol and corticosteroids
How can intracerebral
hemorrhage be managed?
Consult neurosurgery
Why does intracerebral
hemorrhage occur?
Reperfusion-related, or delayed
transformation of a small ischemic
insult
Landmark Research
What did the NASCET (North
American Symptomatic Carotid
Endarterectomy Trial-1991) and
ECST (European Carotid Surgery
Trial-2003) trials find regarding
CEA versus medical management
alone for symptomatic patients?
Significant benefit for CEA
with medical therapy over
medical management alone
for symptomatic patients
with 70–99% stenosis:
NASCET also found
a benefit for CEA in the
moderate stenosis group
(50–69%), while ECST did
not.
What did the ACAS
(Asymptomatic Carotid
Atherosclerosis Study-
1995)
and ACST (Asymptomatic
Carotid Surgery Trial-2010)
trials find regarding CEA versus
medical management alone for
asymptomatic patients?
Significant benefit for CEA
with medical therapy in
asymptomatic patients:
ACAS: with >60%
stenosis versus medical
therapy alone
ACST: with
hemodynamically
significant stenosis versus
deferring CEA
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CAS Versus CEA
What did the
CAVATAS
(Carotid and
Vertebral Artery
Transluminal
Angioplasty
Study-1999) study
find regarding
CEA versus
endovascular
therapy in
symptomatic
patients with
low to moderate
surgical risk, and
what was a major
limitation in the
endovascular arm?
Findings:
Similar short- and long-term stroke
and mortality rates between CEA and
endovascular therapy
Less other complications in the endovascular
arm
Similar 30-day and 3-year effectiveness rates
Higher restenosis rate in the endovascular
arm especially longer term
Limitations:
No use of cerebral protection devices, as this
was prior to their invention
Low stenting rate in endovascular arm,
mostly just angioplasties
What was a
unique feature of
the SAPPHIRE
(Stenting and
Angioplasty with
Protection in
Patients at High
Risk for Endarter-
ectomy-2004) trial,
and what were its
major findings and
limitations?
Unique feature:
Only RCT comparing outcomes in high
surgical risk patients (both symptomatic and
asymptomatic) undergoing CEA vs CAS with
an EPD
Findings:
Favorable results for CAS over CEA at
30days and 1year but mostly did not reach
significance as study was stopped early for low
enrollment.
Equally effective at 3-year follow-up in
terms of stoke prevention.
Carotid artery stenting is non-inferior to
CEA in 30-day risk of stroke, death, and MI.
There was a statistically significant lower
rate of MI in the CAS population at 30days.
Limitations:
Controversial as lab findings of cardiac
biomarkers were used to diagnose MI, not
necessarily EKG findings or symptoms.
The study stopped early for low enrollment,
so many endpoints did not reach significance.
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What were the
major findings and
limitations of the
EVA-3S
(Endarterectomy
Versus Angioplasty
in Patients with
Symptomatic
Severe Carotid
Stenosis-2006),
SPACE (Stent-
Supported
Percutaneous
Angioplasty of the
Carotid Artery
Versus
Endarterectomy-
2006), and ICSS
(International
Carotid Stenting
Study-2010) trials
comparing CAS
and CEA in
symptomatic
patients with
standard surgical
risk?
Findings:
Overall: no significant difference in long-term
outcomes between CEA and CAS
EVA-3S:
Terminated early after much higher negative
outcome rate in the CAS arm at 30days
However beyond 30days no difference in
adverse outcomes
SPACE:
Terminated early due to low enrollment
No significant difference in outcomes (stoke,
death) between CAS and CEA at 30days or
2years
CAS better for patients <70years old, and
CEA better for patients >70years old
ICSS:
CEA was superior to CAS in terms of major
negative outcomes (stroke, death, MI) at
120days follow-up:
But at 5years=no significant difference in
major outcome including mortality or disabling
stroke
Non-disabling stroke was higher in stenting
group, but no difference in quality of life or
disability.
Limitations:
Both EVA-3S and SPACE required very
minimal operator experience in the CAS arms.
EVA-3S:
5 prior CAS procedures if unsupervised, 0 if
supervised:
Trainees with little stenting experience could
perform CAS if proctored by qualified operators.
SPACE:
Operators needed to have a minimum number
of successful CEAs.
Also needed a minimum number of
endovascular angioplasty or stenting procedures
in the past, but did not have to be CAS.
EVA-3S also used single-antiplatelet medical
therapy after stenting, as compared to gold-
standard dual-antiplatelet therapy.
The use of EPDs was limited, not mandatory,
and nonuniform in all three trials.
(continued)
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