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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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Urgent carotid treatment : what is changed ?

Years Neurological exam Intervention NIHSS pre NIHSS post

43 Stroke minor CEA 7 2

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Urgent carotid treatment : role for CAS ?

+

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Urgent CAS treatment : theoretically advantages

Reducingprocedural time

Reducingischemic time

Gold standardin the diagnosis

Possibility oftreating

tandem-lesions

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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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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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Slide 20

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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High risk patients,elderly, with tortuos

vessels andproblematic

accesses

Patients andlesions

Unstable plaque withvulnerability features

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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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Patients andlesions

High risk patients, elderly,anziani , with tortuos vessels

and problematic accesses

Unstableplaque with

vulnerabilityfeatures

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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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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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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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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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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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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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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