Left CAS for ulcerated Carotid stenosis, Difficult femoral access

Educational objectives

• Plan a step-by-step carotid artery stenting procedure.
• How to manage access through tortuous anatomy?
• How to proceed to a safe and successful catheterization of the left carotid artery?
• Materials choice: guidewires, filter, guiding catheter, balloons and 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 Micromesh Roadsaver® stent
• 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: Echo guided 8 French access using micro puncture system.
• Heparin administration.

2) Left common carotid artery catheterization: coaxial technique

• Continuous purging of the guiding catheter while introducing guidewire, embolic protection device, balloons or stent.
• Advance an 8 Fr Hockey Stick guiding catheter to the aortic arch on a 0.035’’ GLIDEWIRE ADVANTAGE® Guidewire.
• Gentle Catheterization of the ostium of the left common carotid artery.
• Advance the 0.035” ADVANTAGE® Guidewire to the external carotid artery.
• Advance a Beacon® Tip 5.0 Fr catheter on the 0.035” ADVANTAGE® Guidewire.
• Exchange to a 0.035” Amplatz Super Stiff™ Guidewire to provide enough support to the Hockey stick 8 Fr guiding catheter to navigate through tortuosity using the coaxial system.
• 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.li>
• Pre dilatation of the lesion using a 5.5*20mm Ultra-Soft™ balloon.
• Checking pre dilatation result

5) Stenting

• Select the precise spot of stent deployment
• Deployment of the Roadsaver 9*20mm stent.
• Be sure that the dual layer markers are on either side of the lesion.

6) Post-dilatation

• Post dilatation of the lesion using a 6*20mm Ultra-Soft™ balloon.
• Checking post dilatation result.

7) Retrievement of embolic protection system: FilterWire EZ™:

• 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

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

10) Medical adjunctive treatments

• Pre-procedural: Heparin and Antibioprophylaxis.
• Post procedural: Triple therapy: Aspirin 75mg o.d. + Clopidogrel 75mg o.d. + Enoxaparin 100 UI/kg b.i.d. : 15 days.
• DUS 15 days after.
• Stop Clopidogrel and continue Aspirin 75mg b.i.d and NAOC.

Bibliography

4. Protected versus Unprotected Carotid Artery Stenting : Meta-Analysis of the Current Literature. Cho YD, Kim S-E, Lim JW, Choi HJ, Cho YJ, Jeon JP. J Korean Neurosurg Soc. 1 juill 2018;61(4):458‑66.

5. Very Low Rate of New Brain Lesions After Vulnerable Carotid Artery Stenting Cases Using Only FilterWire EZ as Distal Embolic Protection. Ishida A, Asakuno K, Shiramizu H, Yoshimoto H, Nakase K, Kato M, et al. World Neurosurg. sept 2020;141:e145‑50.

6. Mesh-covered (Roadsaver) stent as a new treatment modality for symptomatic or high-risk carotid stenosis. Machnik R, Paluszek P, Tekieli Ł, Dzierwa K, Maciejewski D, Trystuła M, et al. Adv Interv Cardiol. 2017;2:130‑4.

7. Carotid artery stenting with a new-generation double-mesh stent in three high-volume Italian centres: clinical results of a multidisciplinary approach. Nerla R, Castriota F, Micari A, Sbarzaglia P, Secco GG, Ruffino MA, et al. EuroIntervention. août 2016;12(5):e677‑83.

8. Efficacy of post-dilatation during carotid artery stenting for unstable plaque using closed-cell design stent evaluated by optical coherence tomography. Harada K, Kajihara M, Sankoda Y, Taniguchi S. J Neuroradiol. nov 2019;46(6):384‑9.

9. The Roadsaver Stent to Treat Carotid Lesions. Bosiers M, Ocke Reis PE. J Vasc Endovasc Surg [Internet]. 2017 [cité 11 mai 2021];02(02).

10. The CLEAR-ROAD study: evaluation of a new dual layer micromesh stent system for the carotid artery. Bosiers M, Deloose K, Torsello G, Scheinert D, Maene L, Peeters P, et al. EuroIntervention. août 2016;12(5):e671‑6.

Procedure

• Procedure time: 25 min
• Exposure time: 20,4 min
• R: 296 mgy
• Contrast volume : 120ml