Proximal protection in CAS: rationale and recent findings from clinical trials - PowerPoint PPT Presentation

Loading...

PPT – Proximal protection in CAS: rationale and recent findings from clinical trials PowerPoint presentation | free to view - id: ef0c6-ZDc1Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Proximal protection in CAS: rationale and recent findings from clinical trials

Description:

Proximal protection in CAS: rationale and recent findings from ... Main afferent vessels. Internal Carotid Arteries. Vertebral Arteries. Main efferent vessels ... – PowerPoint PPT presentation

Number of Views:77
Avg rating:3.0/5.0
Slides: 32
Provided by: villamari
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Proximal protection in CAS: rationale and recent findings from clinical trials


1
Proximal protection in CAS rationale and recent
findings from clinical trials
A. Cremonesi F. Castriota
Interventional Cardio-Angiology Unit Villa
Maria Cecilia Hospital Cotignola (RA) - Italy
2
Potential conflicts of interest
Alberto Cremonesi, MD ? I have the following
potential conflicts of interest to report ?
Consulting ? Employment in industry ?
Stockholder of a healthcare company ? Owner of
a healthcare company ? Other(s). ? I do not
have any potential conflict of interest
3
Background
4
Cerebral Protection Strategies
  • Proximal device drawbacks
  • 9-10 F Introducer Sheath compatibility
  • patient with peripheral diffuse disease and
    previous ipsilateral PTA
  • Interruption of brain perfusion during the
    intervention
  • Intolerance to occlusion takes place in 3-8 of
    the cases
  • Filter wire drawbacks
  • Wall apposition
  • Tortuous / diseased landing zone
  • Intracranial ICA gt 7 mm
  • Small particles (embolic shower)
  • Distal occlusive balloon drawbacks
  • Neurological intolerance
  • ECA embolization

5
Filter Protection
  • Filter Protection Upsides
  • Maintenance of cerebral perfusion
  • Very intuitive device for beginners
  • Filter Protection Downsides
  • Pass lesion unprotected
  • Need for a suitable landing zone in the ICA
  • Unreliable vessel wall apposition
  • Emboli passing through and by the filter
  • Difficulty to negotiate tortuous anatomies, tight
    lesions
  • Trauma to the target diseased ICA vessel
  • Suboptimal system stability

6
Endovascular Clamping
  • CEA concept applied to endovascular technique

Y 1999
7
Endovascular Clamping
  • CEA concept applied to endovascular technique

8
Cerebrovascular Basics
9
Cerebral Perfusion
10
Cerebral Blood Supply
  • Circle of Willis
  • Anastomotic network between the two cerebral
    hemispheres
  • Main afferent vessels
  • Internal Carotid Arteries
  • Vertebral Arteries
  • Main efferent vessels
  • Anterior Cerebral Arteries
  • Middle Cerebral Arteries
  • Posterior Cerebral Arteries

Inferior View
11
CCA Clamping
CCA Clamping
Occurrence of retrograde blood flow through
ipsilateral ECA
12
ECA Clamping
CCA Clamping
ECA Clamping
  • No Flow confirmed by stagnation of contrast
    medium

13
ECA Clamping
CCA Clamping
ECA Clamping
  • BACK Pressure at the Carotid
    Bifurcation

14
Proximal Flow Blockage vs Flow Reversal
  • No blood backflow ? no blood stealing from the
    ipsilateral hemisphere through the ipsilateral
    ICA
  • Maintanence of cerebral perfusion through the
    efferent vessels of the Circle of Willis
  • Anterior Cerebral Arteries
  • Middle Cerebral Arteries
  • Posterior Cerebral Arteries

15
Device Overview
16
Proximal Flow Blockage Concept
  • Cerebral Protection
  • Proximal flow blockage at the carotid bifurcation
    by CCA and ECA clamping
  • antegrade blood flow from CCA
  • retrograde blood flow from ECA
  • Debris Removal
  • Syringe blood aspiration

17
The MO.MA Device
  • Guiding Sheath integrating two highly compliant
    balloons
  • 6F I.D. fully usable Working Channel
  • 9F O.D. shaft

18
Reversal Flow Concept
19
Reversal Flow Concept
20
GORE Device specification
21
Clinical Data
22
(No Transcript)
23
(No Transcript)
24
Reimer B. et al.
25
(No Transcript)
26
(No Transcript)
27
MO.MA Clamping Time / Intolerance
28
  • Carotid stenting performed in 56 patients with
    Parodi Anti-Emboli System.
  • The patients neurologic status was assessed
    during the intervention at discharge 1, 6, and
    12 months after the procedure and yearly
    thereafter.
  • Technical success 100
  • 30 day all stroke and death rate 1.8
  • During follow-up
  • intra-cerebral bleeding and stroke 3.6
  • Absence of restenosis gt 50 at the site of the
    occlusion balloon in the CCA or at any other site
    of the ipsilateral carotid arteries.

29
Cerebral protection during carotid stenting using
flow reversal. Parodi JC, Ferreira LM, Sicard
G, La Mura R, Fernandez S.
J Vasc Surg. 2005 Mar41(3)416-22
  • Carotid angioplasty and stenting was performed in
    100 patients (84 men mean age, 69.2 years) with
    symptomatic (26) or asymptomatic (74) severe
    carotid artery stenosis.
  • Wallstents were used in all cases with selective
    pre-dilatation.
  • Parodi Anti-Emboli System PAES were used in all
    patients.
  • Overall perioperative stroke and death rate 3
  • 1 noncorresponding minor stroke, 1 hemorrhagic
    stroke, and 1 cardiac event.
  • Four patients developed postoperative transient
    neurologic events (three related to hemodynamic
    instability and the fourth due to postoperative
    embolization).
  • Overall technical success rate (protection device
    placed in position percutaneously) 99

30
Conclusions
  • Results of controlled studies indicate that
    proximal protection systems can successfully be
    applied during carotid artery stenting.
  • The proximal protection systems proved to be
    feasible and safe, with a high technical success
    rate.
  • A clamping intolerance without clinical sequalae
    and without interruption of the procedure has
    been observed in a few cases.
  • The neurologic complication rate is similar to
    that reported by other controlled studies of
    protected CAS.

31
Proximal protection in CAS Indications
  • Applicable, safe and effective in most of
    anatomical / clinical settings
  • 1st Choice in High Embolic Risk Lesions
  • Soft ulcerated plaques
  • Long, sub-occlusive lesions
  • Diffuse diseased ICAs
  • Friable, unstable plaque by
  • Echo Doppler and angiographic findings
  • Recent, recurrent symptoms (i.e. patients with
    stuttering TIAs)
  • Fresh thrombus lesions (?)
  • Recommended in Challenging Anatomies
  • Difficult to access ICAs due to very angulated
    ICA-CCA take-off and tortuous ICAs
  • Lack of a suitable ICAs landing zone for distal
    protection
About PowerShow.com