Avoiding and Managing Complications During CAS: Lessons Learned

Transcription

1 LINC 2019 Leipzig, Germany, Jan 22-25, 2019 Avoiding and Managing Complications During CAS: Lessons Learned Horst Sievert, Ilona Hofmann, Kolja Sievert, Laura Vaskelyte, Sameer Gafoor, Stefan Bertog, Predrag Matić, Markus Reinartz, Bojan Jovanovic, Iris Grunwald, Nalan Schnelle CardioVascular Center Frankfurt - CVC, Frankfurt, Germany

2 Disclosures Physician name Company Relationship Horst Sievert 4tech Cardio, Abbott, Ablative Solutions, Ancora Heart, Bavaria Medizin Technologie GmbH, Bioventrix, Boston Scientific, Carag, Cardiac Dimensions, Celonova, Comed B.V., Contego, CVRx, Dinova, Edwards, Endologix, Hemoteq, Lifetech, Maquet Getinge Group, Medtronic, Mitralign, Nuomao Medtech, Mokita, Occlutech, pfm Medical, Recor, Renal Guard, Rox Medical, Terumo, Vascular Dynamics, Venus, Vivasure Medical Consulting fees, Travel expenses, Study honoraria to institution

3 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management

4 Patient Selection General risk factors - Comorbidities - Age Morphologic risk factors - Difficult access Iliac tortuosity, aortic arch type III, elongated CCA - Lesion morphology Thrombus, large plaque - Morphology of the distal ICA Elongation, kinking - Contralateral occlusion, isolated hemishere

5 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management

6 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management

7 Medication Discontinue drugs inducing bradycardia and hypotension - ß-Blocker, Ca antagonists Aspirin + Plavix 1 week before Don't treat hypertension during the procedure before the stent is implanted Heparin (5,000-7,500 units or ACT controlled) Atropine before balloon inflation Catecholamines if needed

8 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management

9 Complications during access Catheter manipulation in the aortic arch is a major source of cerebral embolism - Use appropriate catheters and techniques Avoid air embolism and thromboembolism - Always de-air the sheath after introducing something - Always flush the sheath when you have blood inside

10 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management Strictly avoid touching the plaque with the wire

11 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management

12 Have different EPD available and consider: Proximal and distal tortuosity Distal landing zone Thrombus and plaque load External carotid artery open? Distal CCA diseased?

13 Avoid malposition of filters Verify position!!

14 With prox occlusion: Avoid flow from the ECA into the ICA The Suprathyreoid artery has to be occluded otherwise there is zero protection!

15 In our experience, the use of prox. protection in all patients has dramatically reduced the 30 day stroke rate 207 consecutive patients regardless of anatomy - No periprocedural stroke - One stroke after discharge due to stent thrombosis 30 day stroke rate < 0.5% First 124 patients: Hornung M et al: Sievert H et al, CRT 2016

16 If embolism occurs: Be prepared for intracranial rescue Middle cerebral artery branch occluded Recanalization using microcatheters

17 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management

18 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management

19 Stent Selection Avoid stiff stents in elongated vessels

20 Double layered stents prevent complications Catheter Cardiovasc Interv. 2018;91:

21 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management

22 New Concept: Paladin Double filtration Integrated Embolic Protection (IEP) TM Integrated Filter: 40 Micron pores Baseline closed Sheathless Angioplasty Balloon Catheter The first device that combines an embolic protection filter and balloon 40 micron pore size allows micro-embolic capture Filter size can be adjusted to suit each patient s unique anatomy

23 Using PALADIN, clinical outcome was superior compared to almost all other carotid stenting studies Paladin Study: patients No procedural Stroke unrelated stroke 2 Low stroke rate Day MAE defined as death, stroke or MI References available for individual study results Prospective multi-center studies with >100 patients

24 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management

25 Complications can occur at each step Patient selection Center and operator selection Medication Getting access Crossing the lesion Embolic protection Pre-dilatation Stent selection and implantation Post-dilatation Retrieval of embolic protection device Post stent management

26 Post stent Keep BP low to prevent hyperperfusion syndrome If BP is too low + symptoms - give pressors Bradycardia - give atropin Aspirin & Plavix for 4 weeks

27 In Conclusion The complication rate of CAS is much lower today All the old randomized trials as well as the ongoing randomized trials are outdated!

28 Thank you!

29 LINC 2019 Leipzig, Germany, Jan 22-25, 2019 Avoiding and Managing Complications During CAS: Lessons Learned Horst Sievert, Ilona Hofmann, Kolja Sievert, Laura Vaskelyte, Sameer Gafoor, Stefan Bertog, Predrag Matić, Markus Reinartz, Bojan Jovanovic, Iris Grunwald, Nalan Schnelle CardioVascular Center Frankfurt - CVC, Frankfurt, Germany