Malm 18 May , 2011

Urgent CAS

G. COPPI, R. MORATTO

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Urgent carotid treatment was abandoned due to

MORTALITY > 42%

Joint study of extracranial arterial occlusion 1969
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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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Urgent carotid treatment: failure causes

Late intervention( > 12 hour)

Lack of neuroimaging
Lack of patient selection

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Urgent carotid treatment: re-consideration

Thrombolysis in acute stroke

doesnt lead to an increasing risk of hemorragic

The urgent revascularization of

a cerebral ischemic infarction could be favourable

conversion
(Wardlaw '92)
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(Cuming '92)

Severity of stroke : a controindication for early treatment

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Urgent carotid treatment: rationale

Stopping embolisation Stopping growth of the thrombus Saving area of ischemic penumbra

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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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Symptomatic carotid stenosis : risk of stroke

Rothwell PM et al., Lancet Neurol 2006

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Symptomatic carotid stenosis : risk of stroke

Risk of major stroke 5% 8-20% 10-25%

Time Within 2 days Within 30 days Within 90 days

IMPENDING STROKE

Rothwell PM et al., Lancet Neurol 2006

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stroke treatment : our protocol in early 90

Duplex-scan
+ -

Urgent CT-scan DSA

Intensive care unit (ICU)

Lack of stroke unit

CEA in emergency

Lack of Neuroimaging

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Urgent carotid treatment : what is changed?

Years 43

Neurological exam
Stroke minor +

Carotid lesion Thrombus

Brain lesions Multiple lesions in right emisphere

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Urgent carotid treatment : what is changed ?

Years 43

Neurological exam Stroke minor

Intervention CEA

NIHSS pre 7

NIHSS post 2

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Urgent carotid treatment : role for CAS ?

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Urgent CAS treatment : theoretically advantages

Reducing procedural time

Reducing ischemic time

Gold standard in the diagnosis

Possibility of treating tandem-lesions

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Urgent CAS treatment : disadvantages

Availability of endovascular team

Availability of radiological suite

Manipulation in vulnerable plaque

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Urgent CAS treatment : emerging data

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Urgent carotid treatment :our TIAs protocol

Recurrent TIAs

High Score alto ABCD2ABCD2 Score

Placca instabile Appropriate symptoms

Unstable plaque

Sintomi appropriati
yes no

Immediate treatment

Within 12 hours

Within 36 hour

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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

cerebral ct-scan & fibrinolysis

yes
Treatment

no
Evaluation case by case

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Urgent carotid treatment :our stroke protocol

Anatomy suitable for surgery (access, neck, bifurcation..) Young patients (at low risk)
yes no

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CEA

CAS ( with 2 skilled operators)

Urgent CAS: avoiding domino effect

DISASTER

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Patients and lesions

High risk patients, elderly, with tortuos vessels and problematic accesses
Unstable plaque with vulnerability features

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Elderly patients and aortic arch

Reducing manipulation Stabilizing catheters

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Reducing manipulation of the arch and Stabilizing catheters

A pivot catheter with two guidewires

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Patients and lesions

High risk patients, elderly, anziani , with tortuos vessels and problematic accesses

Unstable plaque with vulnerability features

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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 of PROLAPSE of the plaque

Closed cell stent or hybrid stent

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Slow dilation : 1 atmosphere / 2 sec.

11 10 9 8

12

1 2 3 4

Avoiding sudden bradicardia or asystolia Avoiding scissoring effect in soft plaques Avoiding plaque suction with prolapse
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Case 1 : acute ICA thrombosis

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Case 1 : acute ICA thrombosis

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Case 2 : ICA preocclusive stenosis with occlusion of peri-calloseal artery

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Case 2 : ICA preocclusive stenosis with occlusion 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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Urgent CAS vs CEA : our experience

Demographic data & symptoms Male Female Mean age TIAs ( within 12 hours) Crescendo TIA Minor stroke Major stroke CAS ( 73 pts.) 55 18 76.7
( min. 50 max. 88)

CEA ( 72 pts. ) 52 20 67.4

( min.43-max.79)

Total ( 145 pts.) 107 38

22 25 21 5

15 42 12 3

37 67 33 8

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May 2005 April 2011

Urgent CAS vs CEA :our experience

Procedural data CAS

Percutaneous femoral access

EPD
Filters Mo.Ma ( blocked flow)

73 (100%)
73( 100%)
12 61

STENTS
Closed or hybrid cells Open cells

84
60 24 6.8 min

Average fluoroscopy time

Average procedure time

Average clamping time ( with Mo.Ma)

54 min
4.1 min May 2005 April 2011

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Urgent CAS vs CEA : our experience

TIA
Immediate results Technical success Deaths Worsening of NIHSS scale MI
Local complications ( Haematoma)

STROKE
CEA 100% 0 CAS 100% 0 CEA 100% 0

CAS 100% 0

1/47
1 1

1/57
0 1

3/26
0 1 May 2005 April 2011

2/15
1 1

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Considerations
Urgent CAS represents a possible solution , complementary to the CEA , in a strategy of tailored treatment , based on anatomy, patients and lesion features , also in neurological unstable situations

CEA

Complementary Not alternative

CAS

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