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    Slide 1

    G. COPPI, R. MORATTO

    Urgent CAS

    Malm 18 May , 2011

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    Slide 2

    Urgent carotid treatment was

    abandoned due to

    MORTALITY > 42%

    Joint study of extracranial arterial occlusion 1969

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    Slide 3

    Urgent carotid treatment: problems

    Risks of early cerebral revascularisation

    Trasforming an ischemic infarct in an hemorragic one

    Revascuralisation oedema

    Brain embolisation

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    Slide 4

    Urgent carotid treatment: failure causes

    Late intervention( > 12 hour)

    Lack of neuroimaging

    Lack of patient selection

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    Slide 5

    Urgent carotid treatment: re-consideration

    Thrombolysis in acute stroke

    doesnt lead to an increasing

    risk of hemorragic

    conversion

    (Wardlaw '92)

    The urgent revascularization of

    a cerebral ischemic infarction

    could be favourable

    (Cuming '92)

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    Slide 6

    Severity of stroke : a controindication for earlytreatment

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    Slide 7

    Urgent carotid treatment: rationale

    Stopping embolisation

    Stopping growth of the thrombus

    Saving area of ischemic penumbra

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    Slide 8

    Urgent carotid treatment: scenarios

    TIA s( not occular )

    Crescendo TIAs: 3 or more

    Minor stroke ( in evolution)

    Major stroke( no coma , lesion at MR-diffusion < 2.5 cm)

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    Slide 9

    Symptomatic carotid stenosis : risk of stroke

    Rothwell PM et al., Lancet Neurol 2006

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    Slide 10

    Rothwell PM et al., Lancet Neurol 2006

    IMPENDINGSTROKE

    Risk of majorstroke

    Time

    5% Within 2 days

    8-20% Within 30 days

    10-25% Within 90 days

    Symptomatic carotid stenosis : risk of stroke

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    Slide 11

    stroke treatment : our protocol in early 90

    Duplex-scan

    Urgent CT-scan

    DSA

    CEA

    in emergency

    Intensive care unit(ICU)

    + -

    Lack of stroke unit

    Lack of Neuroimaging

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    Slide 12

    Urgent carotid treatment : what is changed?

    +

    Years Neurologicalexam

    Carotid lesion Brain lesions

    43 Stroke minor ThrombusMultiple lesions in right

    emisphere

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    Slide 13

    Urgent carotid treatment : what is changed ?

    Years Neurological exam Intervention NIHSS pre NIHSS post

    43 Stroke minor CEA 7 2

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    Slide 14

    Urgent carotid treatment : role for CAS ?

    +

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    Slide 15

    Urgent CAS treatment : theoretically advantages

    Reducingprocedural time

    Reducingischemic time

    Gold standardin the diagnosis

    Possibility oftreating

    tandem-lesions

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    Slide 16

    Urgent CAS treatment : disadvantages

    Availability ofendovascular team

    Availability ofradiological suite

    Manipulation invulnerable plaque

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    Urgent CAS treatment : emerging data

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    Urgent carotid treatment :our TIAs protocol

    ABCD2 Score alto

    Placca instabile

    Sintomi appropriati

    Recurrent

    TIAs

    Immediatetreatment

    High ABCD2 Score

    Unstable plaqueAppropriate symptoms

    Within 12hours

    Within 36hour

    yes no

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    Slide 19

    Urgent carotid treatment :our stroke protocol

    Duplex-scan& neurological exam( neurologist , vascular surgeons)

    Perfusional CT +Angio-CT

    or RM diffusion( neuroradiologist)

    Stroke minor

    Lesion< 2,5 cm.

    No coma

    TreatmentEvaluation

    case by case

    cerebral ct-scan &

    fibrinolysis

    + -

    yes no

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    Urgent carotid treatment :our stroke protocol

    Anatomy suitable for surgery

    (access, neck, bifurcation..)

    Young patients (at low risk)

    CEA

    CAS

    ( with 2 skilled operators)

    yes no

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    Urgent CAS: avoiding domino effect

    DISASTER

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    Slide 22

    High risk patients,elderly, with tortuos

    vessels andproblematic

    accesses

    Patients andlesions

    Unstable plaque withvulnerability features

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    Slide 23

    Elderly patients and aortic arch

    Reducing manipulation

    Stabilizing catheters

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    Reducing manipulation of the arch andStabilizing catheters

    A pivot catheter with two guidewires

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    Slide 25

    Patients andlesions

    High risk patients, elderly,anziani , with tortuos vessels

    and problematic accesses

    Unstableplaque with

    vulnerabilityfeatures

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    Slide 26

    Reduce embolic risk : endovascular clamping

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    Urgent CAS : role for filters ?

    no yes

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    Reducing embolic risk : flushing towards ECA

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    Slide 29

    Urgent CAS: what about the stent ?

    Open cell stent

    Wide gap with possibility ofPROLAPSE of the plaque

    Closed cell stent or hybrid stent

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    Slide 30

    Slow dilation : 1 atmosphere / 2 sec.

    Avoiding sudden bradicardia or asystolia

    Avoiding scissoring effect in soft plaques

    Avoiding plaque suction with prolapse

    67

    8

    121

    2

    3

    4

    5

    9

    10

    11

    C ICA h b i

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    Slide 31

    Case 1 : acute ICA thrombosis

    C 1 ICA h b i

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    Case 1 : acute ICA thrombosis

    C 2 ICA l i t i ith

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    Case 2 : ICA preocclusive stenosis withocclusion of peri-calloseal artery

    C 2 ICA l i t i ith

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    Case 2 : ICA preocclusive stenosis withocclusion of peri-calloseal artery

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    Case 3 : ICA stenosis with MCA occlusion

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    Case 3 : ICA stenosis with MCA occlusion

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    Slide 37

    Demographic data

    & symptomsCAS ( 73 pts.) CEA ( 72 pts. ) Total ( 145 pts.)

    Male 55 52 107

    Female 18 20 38

    Mean age

    76.7

    ( min. 50 max. 88)

    67.4

    ( min.43-max.79)

    TIAs ( within 12hours)

    22 15 37

    Crescendo TIA 25 42 67

    Minor stroke 21 12 33

    Major stroke 5 3 8

    May 2005

    April 2011

    Urgent CAS vs CEA : our experience

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    Procedural data CAS

    Percutaneous femoral access 73 (100%)

    EPD 73( 100%)

    Filters 12

    Mo.Ma ( blocked flow) 61

    STENTS 84

    Closed or hybrid cells 60

    Open cells 24

    Average fluoroscopy time 6.8 min

    Average procedure time 54 min

    Average clamping time ( with Mo.Ma) 4.1 min

    Urgent CAS vs CEA :our experience

    May 2005 April 2011

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    Slide 39

    Urgent CAS vs CEA : our experience

    May 2005 April 2011

    Immediate results CAS CEA CAS CEA

    Technical success 100% 100% 100% 100%

    Deaths 0 0 0 0

    Worsening of NIHSSscale

    1/47 1/57 3/26 2/15

    MI 1 0 0 1

    Local complications( Haematoma)

    1 1 1 1

    TIA STROKE

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    Slid 40

    Considerations

    CEAComplementary

    Not

    alternative

    CAS

    Urgent CAS represents a possible solution , complementaryto the CEA , in a strategy of tailored treatment , based on

    anatomy, patients and lesion features , also in neurologicalunstable situations