Protected Carotid Artery Stenting with a new micromesh carotid stent

This didactic procedure concerns a 70 years old man presenting with asymptomatic severe calcified and ulcerated left internal carotid on echography. Angiography revealed a severe ulcerated stenosis of the left internal carotid artery.

Educational objectives

• Plan a step-by-step carotid artery stenting procedure.
• 48 hours of dual antiplatelet therapy before the procedure;
• Interruption of anti-hypertensive therapy the day before
• How to manage access through tortuous anatomy?
• Materials choice: guidewires, protection filter, guiding catheter, balloons and carotid stent.
• How to prepare, advance the embolic protection system: FilterWire EZ™ through the lesion and release the filter upstream the lesion?
• Tips and tricks for a good positioning and implantation of the Mesh carotid stent: CGUARD™EPS
• How to safely retrieve the embolic protection system: FilterWire EZ™?
• What are adjunctive per procedural pharmacotherapies

Step-by-step procedure: Left internal carotid artery stenting

1) Access sites:

• Femoral access: 8 French access using micro puncture system.
• Heparin administration.

2) Left common carotid artery catheterization:

• Continuous flushing of the guiding catheter while introducing guidewire, embolic protection device, balloons or stent.
• Advance softly an 8 Fr Hockey Stick guiding catheter to the aortic arch over a 0.035’’ GUIDEWIRE
• Gentle Catheterization of the ostium of the left common carotid artery.
• Advance the 0.035” Guidewire towards the common carotid artery.
• Advance the guiding catheter to the distal part of the common carotid artery with the tip oriented towards the internal carotid ostium.

3) Preparation and deployment of embolic protection system: FilterWire EZ™:

• Preparation of the filter with a special attention to avoid air bubbles.
• Preform the wire tip shape according to the lesion morphology.
• Careful and gentle crossing of the lesion avoiding plaque destabilization.
• Release the filter in a vertical segment of the internal carotid distally to the lesion: be sure to have enough space for stent distal landing zone.
• Verify the good position and the opening of the filter under fluoroscopy.

4) Pre-dilatation

Atropine administration

• Good balloon preparation: avoid air bubbles to avoid cerebral air embolism in case of balloon rupture.
• Pre dilatation of the lesion using a 4*20mm Ultra-Soft™ balloon , inflated to 4 ATM
• Checking pre dilatation result

5) Stenting

• Select the precise spot of stent deployment
• Deployment of the CGUARD™EPS 9x30 mm Stent

6) Post-dilatation

• Post dilatation of the lesion using a 5,5 *20mm Ultra-Soft™ balloon. Inflated to 15 ATM
• Checking post dilatation result

7) CT scan after procedure showed : Excellent deployment of the stent

• Check the filter content and the quality of the flow.
• Remove the filter.
• Verify if there is any dissection or spasm.

8) Final angiographic control: Cervical and Intra-cranial ( 2 views frontal & lateral)

9) Vascular femoral closure with an 8 Fr Angio-Seal™

10) Medical adjunctive treatments

• Pre-procedural: Heparin.
• During procedure : Atropine and ephedrine
• Post procedural : double therapy: Aspirin 75mg o.d. + Clopidogrel 75mg o.d for one month
• After one month : Stop Clopidogrel and continue Aspirin 75mg

Bibliography