Tailored carotid artery stenting

Transcription

1 Tailored carotid artery stenting is associated with a low complication rate 30-day results from the continued TARGET-CAS study in 1133 consecutive procedures. Lukasz Tekieli, Piotr Pieniazek, Piotr Musialek, Anna Kablak-Ziembicka, Rafal Motyl, Tadeusz Przewlocki, Mariusz Trystula, Marta Hlawaty, Piotr Paluszek, Zbigniew Moczulski, Krzysztof Zmudka, Piotr Podolec JAGIELLONIAN UNIVERSITY DEPT. OF CARDIAC & VASCULAR DISEASES JOHN PAUL II HOSPITAL, KRAKOW, POLAND

2 Acceptable risk of CEA/CAS complications according to ACC/AHA (2007) and ESVS (2009)

3 TAILORED -CAS principles (2001) comprehensive patient evaluation non-invasive imaging: extra/intracranial Doppler extra/intracranial CT-angio brain CT independent neurological consultation patient-and-lesion-tailored neuroprotection and stent type coronary angiography immediately prior to CAS rigorous follow-up

4 TAILORED -CAS ALGORITHM Tailored carotid artery stenting symptomatic LICA & 2009; 16: P Pieniazek, P Musialek, et al.

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6 Aim: to evaluate 30-day safety of CAS with different embolic protection devices and different stent types used according to the Tailored CAS algorithm to identify risk factors for complications in Tailored CAS.

7 Patients characteristics (Jan 2001 May 2010) age (years) 66.1±8.4 (36-88) man 68.5% symptomatic * 49.1% stroke 38.8% TIA 23.1% high-risk lesions 34.8% bilateral carotid disease 31.4% arterial hypertension 88.5% diabetes 26.5% smoking 58.6% hyperlipideamia 84.7% coronary artery disease 63.9% No. of CAS 1133 No. of patients 1032 *history of ipsilateral stroke or TIA soft/thrombus-containing/tight/ulcerated confirmed by angiography

8 Neuroprotection systems Proximal neuroprotection 359 (31.7%) PAES/GoreNPS (Flow Reversal) 193 Mo.Ma 9F/8F (Flow Cessation) 166 Distal neuroprotection 774 (68.3%) FilterWire EZ 309 Emboshield 175 Angioguard 112 Spider RX/FX 77 Accunet 58 PercuSurge 29 Gore Embolic Filter 4 FiberNet 4 Interceptor 3 Defender 3

9 P.A. 58 y.o. ipsilateral TIA 7 days prior to procedure contraindication for distal protection!!!

10 P.A. 58 y.o. ipsilateral TIA 7 days prior to procedure contraindication for distal protection!!! Gore-NPS (flow-reversal system) HT Whisper MS wire Predilatation with 2.0 x 20mm balloon Carotid Wallstent 7.0 x 30mm

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12 J.J. 64 y.o. asymptomatic RICA stenosis RICA 80%; routine intracranial angiography

13 COMPLICATION RICA-CAS FilterWire EZ Xact 9-7x30mm Iatrogenic, embolic occlusion of right medial cerebral artery

14 COMPLICATION MANAGEMENT POBA - Falcon 1.0x10mm rt-pa i.a. injection (10 mg) POBA Sprinter Legend 2.0x15mm rt-pa i.a. injection (10 mg) combined mechanical and pharmacological recanalization

15 COMPLICATION RESOLVED Final angiography and complete resolution of neurological symptoms

16 COMPLICATION RESOLVED 5/1133 (0.44%) cases of peri-procedural intracerebral macro-embolization: all were treated with mechanical + thrombolitic therapy Clinical consequences: 3 TIAs 1 stroke (NIHSS 4) 1 death due to intracranial bleeding Final angiography and complete relief of neurological symptoms

17 S.Z. 55 y.o. left-hemisphere stroke 6 months prior to procedure COMPLICATION diagnostic angiography RCCA dissection Acculink 9x40mm (distal), Acculink 9x30mm (proximal), Fox 8x20mm balloon Final result RICA - Xact 9x40mm RICA 90%, LICA 100%, RCCA iatrogenic dissection

18 O.C. 76 y.o. asymptomatic RICA Doppler 4.7/2.3 m/s low RMCA velocities on TCD LICA occlusion CT normal RICA-CAS RICA 95%

19 O.C. 76 y.o. asymptomatic Laminal flow within a stent Optimal angiographic result of RICA-CAS

20 O.C. 76 y.o., 8 h after CAS headache and right-hemisphere ischaemic symptoms COMPLICATION Pos-procedural 2.7-fold increase in RMCA velocities on TCD (A. Kablak-Ziembicka) Hyperperfusion-associated ipsilateral intracranial bleeding Przewlocki T, Pieniazek P, Kablak-Ziembicka A et al. J Vasc Surg 2007;45: Kablak-Ziembicka A, Przewlocki T, Pieniazek P et al. JEVT2010;17:

21 7/1133 (0.62%) cases of peri-procedural hyperperfusion O.C. 76 y.o., 8 h after CAS headache and right-hemisphere ischaemic Leading symptoms to intracerebral bleeding in 5 all were treated with BP reduction COMPLICATION clopidogrel stopped & ASA maintained in 5 ASA stopped & clopidopidogrel maintained in 2 During hospitalization: death 2 cases minor stroke 2 cases Pos-procedural 2.7-fold increase in RMCA velocities on TCD (A. Kablak-Ziembicka) resolution w/o sequaele 3 cases Hyperperfusion-associated ipsilateral intracranial bleeding Przewlocki T, Pieniazek P, Kablak-Ziembicka A et al. J Vasc Surg 2007;45: Kablak-Ziembicka A, Przewlocki T, Pieniazek P et al. JEVT2010;17:

22 Complications by 30-days (n=1133 CAS) PERIPROCEDURAL COMPLICATIONS death 0.53% disabling stroke 0.09% minor stroke 1.68% myocardial infarct 0.00% TIA 3.79% hyperperfusion 0.62% EPD intolerance 2.73% ICA spasm 2.21% ICA/CCA dissection 0.44% hypotonia requiring catecholamin infusion 1.32% anaemia requiring blood transfusion 0.35% COMPLICATIONS AFTER DISCHARGE death 0.09% disabling stroke 0.00% minor stroke 0.26% myocardial infarction* 0.00% TIA 0.44% *Coronary angio performed prior to CAS PCI prior to CAS 5.9% PCI after CAS 3.0% CABG after CAS 2.2% Hybrid CAS/CABG 0.5%

23 Complications by 30-days (n=1133 CAS) PERIPROCEDURAL COMPLICATIONS death 0.53% disabling stroke 0.09% minor stroke 1.68% myocardial infarct 0.00% TIA 3.79% hyperperfusion 0.62% EPD intolerance 2.73% ICA spasm 2.21% ICA/CCA dissection 0.44% hypotonia requiring catecholamin infusion 1.32% anaemia requiring blood transfusion 0.35% COMPLICATIONS AFTER DISCHARGE death 0.09% disabling stroke 0.00% minor stroke 0.26% myocardial infarction* 0.00% TIA 0.44% 30-day death/disabling stroke 0.71% 30-day death / any stroke 2.65% symptomatic pts 3.42% asymptomatic pts 1.58%, p=0.06

24 Complications by 30-days (n=1133 CAS) PERIPROCEDURAL COMPLICATIONS death 0.53% disabling stroke 0.09% minor stroke 1.68% myocardial infarct 0.00% TIA 3.79% hyperperfusion 0.62% EPD intolerance 2.73% ICA spasm 2.21% ICA/CCA dissection 0.44% hypotonia requiring catecholamin infusion 1.32% COMPLICATIONS AFTER DISCHARGE death 0.09% disabling stroke 0.00% minor stroke 0.26% myocardial infarction* 0.00% TIA 0.44% predictors of 30-day death: age >75y (p=0.013) use of open-cell stents (p=0.049) diabetes (p=0.08) anaemia requiring blood transfusion 0.35%

25 Conclusions In most cases, intracranial embolic complications can be resolved by an immediate intervention combining intracranial PTA and intra-arterial lytic therapy. Therefore CAS centers should have access to appropriate equipment and operators familiar with/trained in intracranial interventions. HYPERPERFUSION leading to intracerebral bleeding (usually bleeding to the prior infarct scar) REMAINS THE MOST SEVERE COMPLICATION. Treatment of the hyperperfusion syndrome remains a challenge. Advanced age and use of open-cells stents are associated with an increased risk of death by 30-days.

26 Take-home message CAS with the EPD and stent type selection according to the Tailored CAS algorithm [JEVT 2008;15:249, JEVT 2009;16:744] IS S A F E >1100 CAS procedures > 1/3 high-risk lesions Complication rate is well-below the guideline-indicated threshold stroke/death 3.4% in symptomatic { <6% } 1.6% in asymtomatic { <3% }