Optimal Stent for a Complex Lesion Carotid Case Review Session

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Relevant Cerebro-Vascular Anatomy for Carotid
Intervention

• Ricardo A Hanel, MD
• Elad Levy, MD
• L N Hopkins, MD

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Cerebrovascular AnatomyWhy should I learn it For
CAS ?

• Basic anatomy and collateral circulation is
  enough
• Always obtain baseline films for comparison
• Knowing the anatomy helps avoid complications

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• 2 ICAs VAs carry 20 of Cardiac OP
• ICAs fixed from skull base to supraclin ICA
• VAs fixed in vertebral foramen

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Carotid artery interventions

• Clinical applied Anatomy will influence
• The best therapeutic option (CEA x CAS)
• The best Access (femoral, brachial, direct)
• Device selection
• Complication avoidance
• Complication management

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Aortic Arch

• Develops from the L 4th embryonic arch
• Branches
• Brachiocephalic trunk (Inominate A)
• L Common carotid A
• L Subclavian A
• Many variations
• Disease alters anatomy and risks

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Aortic Arch Views

• Arch angio to assess access
• LAO 30-45 degrees best
• Multiple viewsorigin ds
• RAO 20.. R subclavian from RCCA

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Positioning for an Ideal Arch Angiogram
30-45 LAO
Straight AP
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Straight and LAO Arch Images
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Aortic Arch Views

• Common Variants
• Bovine origin of LCCA off of Brachiocephalic
  Trunk
• 7-20 of patients
• L Vertebral origin off arch
• 0.5 of patients
• Proximal to L SCA
• Aberrant right subclavian
• 0.4 to 2 of patients
• R Subclavian originates from the arch distal to
  the left subclavian

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Common variants

• A) Brachiocephalic trunk (BCT) and LCCA share a
  common origin (25-30)
• B) L CCA arises from BCT (7)
• C) L Vert arises directly from the arch (0.5)

D) R subcl. Origin from L
Osborn A, 1998
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Bovine Arch - 7?? Brachial Approach
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Uncommon

• L Arch Aberrant R Subclavian (0.4-2)
• R Arch with aberrant L subclavian
• Rt arch with mirror-image branching
• Double Aortic Arch

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What is this??
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Dextrocardia with mirror-image
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And This??
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Multiple AnomaliesWhat s This??
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R Subclavian (No R vert)
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Multiple Anomalies

• Supra-aortic vessels (R to L)
• R CCA
• R Vert from RCCA
• LCCA
• L Vert
• L Subclavian
• R Subclavian

R VA
L CCA
L VA
R CCA
RL Subcl
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R Vert arising from R CCA
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Weird Anatomy!!
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Carotid Artery
Petrous Carotid

• Variability enormous
• Bifurcation C1 T2
• Best working view lat/obl
• Bony landmarks
• -Unsubtract

Skull Base
ICA
ECA
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Cervical Carotid Views

• Obtain AP, Lateral and Oblique projections
• Clear ICA origin from ECA
• Evaluate for dissection, thrombus, calcium, kinks
• Measurements using NASCET criteria
• 1 - (Stenosis diameter/Non-tapered segment
  diameter)

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Cervical ICA No Branches Hi flowDont
overdilate! Fixed near skull base Carotid Sinus
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What is this??
Where to put the filter?
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Connections ICA to VA
Pcomm Otic Primitive trigeminal Hypoglossal Pro
atlantal
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ECA anatomy
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• ECA Branches
• Key source of collateral
• Anastomoses to ICA or VA
• Stent will not occlude ECA

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When handling the ECA remember

• EC-IC anastomosis common
• May not be seen on angiogram
• With major vessel occluson these anastomosis may
  hypertrophy
• ECA embolus may cause stroke
• BE AWARE!

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Most Common Extra-cranial Intra-cranial
anastomosis
EXTRACRANIAL ARTERIES INTRACRANIAL ARTERIES
Anterior branch of middle meningeal Ophthalmic (ethmoidal)
Anterior meningeal Anterior cerebral
Petrosquamosal branch of middle meningeal Petrous internal carotid (cranial nerve VII)
Occipital Vertebral
Neuromeningeal branch of ascending pharyngeal Posterior inferior cerebellar/ anterior inferior cerebellar (cranial nerves IX-XI)
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The GuardWire Balloon Protected Procedure
Post-intervention Cine
E. Deflate the GuardWire protection
balloon and evaluate final result
Pre-intervention Cine
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The GuardWire Balloon Protected Procedure
Carotid stenting sample
SVG with covered stent sample
Complication Visual Loss due to retrograde
embolization of retinal arteries via ECA branches
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ICA Anatomy
Supraclinoid ICA
Petrous ICA
Ophthalmic a
Cavernous ICA
Base of Skull
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Onward and Upward

• ICA becomes fixed 2-3mm proximal to skull base
• Petrous ICA up to supraclinoid ICA fixed in
  bone/ligamentous/dural encasement
• Intracranial vessels more mobile but fragile and
  easily damaged/ruptured

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Skull Base From Below
ANT

• Horizontal Petrous ICA

Post
ICA Entrance
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Skull Base From Above
Ant
Horiz Petrous ICA
Post
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Petrocavernous ICA Side View - Right
Cavernous
Ascending Petrous
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Cavernous Supraclinoid ICA
Anterior Medial Loop
Horizontal Cavernous ICA
Supraclinoid ICA
Post Communicating
Perforators
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Quiz What is this??

• Although uncommon, carotid-basilar anastomoses,
  other then PComm, may occur
• Persistent trigeminal artery (0.25)
• From Cavernous ICA to basilar

Primitive Trigeminal
Ascending Petrous ICA
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Intracranial Vascular Anatomy

• After giving origin to the Ophthalmic A, PComm
  and Ant Choroidal artery the ICA finally
  bifurcates into the Anterior Cerebral Artery -
  ACA and Middle Cerebral Artery MCA

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Intracranial Vascular Anatomy
A Must.pre op AP and Lateral Angio Have them
handy!!!!
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Variations are the Rule

• Many variations of these vessels
• Always have pre op films to compare in case of
  trouble
• And always do a baseline Neuro exam pre op

3 M-2 branches
MCA embolus ?????
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The Circle of Willis

• Connection between
• Carotid-basilar system
• Rt/Lt side
• Vessels involved
• ACAs AComm
• ICAs PComms
• PCAs
• Basilar

T/F The Circle is Always Intact ??
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Pcomm
Acomm
Pcomm
Pcomm
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The Circle of Willis

• The Circle of Willis is complete in only 30-40
  of the cases
• Many variations
• Hypoplasia of one of the A-1 segments of the
  ACAs
• Or ICA stenosis???

A-1
What is this?
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MCA ACA Anatomy
ACA
MCA
ACA A-2
M-2
Acomm
M-1
A-1
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MCA
Where is the ACA ?
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MCA Many Variations
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ACA Anatomy
A-2
A-2
PComm
A-1
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Variations, variations, variations
Message ???
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Vertebral Artery Anatomy
Rich Muscular Collateral
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Department of Radiology
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Variations, variations, variations

• A complete diagnostic angiogram with
  clinical/anatomical correlation should be
  performed and available before any major
  intervention

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What is this??
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Interesting CollateralAsx LCCA origin
stenosisR CCA BILAT VA OCCL
R VA(thyrocervical trunk)
R CCA(inf thyroid a)
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ICA Occlsion
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R ICA Occl with CollateralCircle of Willis
R Vertebral
L Carotid
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R ICA Occl with Pial Collateral
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R ICA Occl with Vertebral Collateral to MCA
PComm
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ICA Occlusion with Ophthalmic Collateral
Ophthalmic To ICA
L CCA
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R ICA Occl with Ophthalmic and Pial Collateral
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Vascular Territories
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Normal AngiogramCapillary Phase
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Capillary Phase

• Pre Embolus

Post Embolus
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Complications

• Interventional procedure going uneventfully
  until..
• Pt agitated hemiparetic
• What is this?
• What should you do?

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ComplicationsIntracerebral Hemorrhage
ACA and MCA spreadBarrel Shift
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Hemorrhage

• CT Scan
• You DO NOT need to angiographically visualize
  extravasation to have bleeding.

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What is This ?
Proceed with CAS ??
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And this ?
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And This ??
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Dangerous AnatomyElderly Patient
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Stay Away!!

• Corkscrew Carotid

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Trouble for sure!
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Judgement!!Backing out is OKCausing a Stroke
is Not
Roubin
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Catheter skills Anatomic Knowledge Better
results

• Conclusion

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