1. Le stenting carotidien par voie cervicale
Une technique simple ? Pour les cas difficiles ? JM CARDON Hopital prive les franciscaines nimes

2. RISQUE CLINIQUE CAS Criteres cliniques : AVC Eva 3s Ipsi+contro 9,6%
527
2000/2005
SPACE
IPSI
6,4%
1183
2001/2006
ICSS
7,4%
1713
2005/2010
CREST
4,1%
2522
2006/2011

3. RISQUE CEREBRAL CAS criteres anatomiques ICSS sub study
124 CAS avec IRM pre/post
Transfemoral+filtre distal
50% nouvelles lesions ischemiques

4. CAS RISQUE ANATOMIQUE 1363 CAS 754 CEA Nouvelle lesion IRM 37%
10%
Metaanalyse KARSTRUP STROKE 2008
IRM PRE ET POST CAS /CEA

5. RISQUE CEREBRAL A LA NAVIGATION QUEL TERRITOIRE ?
ZHU : j vasc surg 2011
Audit neuro + DWI pre /post : 30 CAS
1 minor stroke
131 nouvelles lesions ischemiques IRM
Ipsi : 83,1% Contro : 16,9%
Territoire : c m : 91,6% ipsi et contro
c p : 6,1%
cerebelleuse: 2%

6. QUEL RISQUE A CAS ?
Grossetti : acta chir belg CAS: pas de predilatation ;filtre distal HR color flow mapping TCD intra op + 12 H post op DWI pre/post 4 test psycometriques Audit neuro

7. Minor stroke : 4%
hits per op : 100%
Hits post op : 10%
Nouvelles lesions ischemiques : 44%
Diminution capacites cognitives : 36%

8. DW MRI
Clinical Significance of New White Lesions
Although the fundamental issues of the nature of the embolic particles, precise mechanisms of cerebral injury, and effective prevention remain debated and unclear, recent reports have provided substantial evidence of memory loss, cognitive decline, and dementia related to these so-called silent infarcts.
Gress DR. JACC 2012.

9. DW MRI Clinical Significance of White Lesions
In population-based studies, a strong association has been found between MRI lesions and prevalent cognitive dysfunction and dementia.
The more extensive the MRI lesions, the more severe is the observed cognitive impairment.
Sun X. JACC 2012;60:791–7.

10. En consequence pendant cas
IL EXISTE UN RISQUE CLINIQUE ET ANATOMIQUE
LES HITS ( embol) ONT UNE CONSEQUENCE ANATOMIQUE:PETIRES LESIONS ISCHEMIQUES A L’IRM
MEME SI PAS D’AVC :DIMINUTION DES FONCTIONS COGNITIVES

11. Patients a risque pour la navigation
ANATOMIE DIFFICILE
en amont
Arche bovine
Crosse aortique type 3
Angulation CPG sur la crosse
Tortuosites CP
La bifurcation
naissance horizontale
En aval
boucles et king king

12. Patient a risque pour la navigation: lesion emboligene
Crosse aortique : calcification
debris atheromateux
thrombus
Bifurcation carotidienne
Gros amas calcaire
Trombus
Hemmoragie intraplaque
Lesions tandem

13. Patient a risque pour la navigation age
Meta analyse Bonati :eur j vasc 2011
eva3s space icss : 3433 patients
TCMM a 120 jours : 8,9%
age seul subgroup significatif:
age<70 ans:5,8%
age>70 ans:12%

14. Il existe donc un risque a la navigation
Navigation dans la crosse =risque AVC homo,contro et post
Navigation dans CP et dans CI= risque AVC homolateral
Franchissement de la lesion par le filtre est dangereux
Lesions intimales sur CI distales liees au filtre= HITS

15. Transfemoral CAS Low risk of MI and CNI but increased peri-procedural stroke risk
In the periprocedural period, the CAS arm in CREST had an excess of stroke (4.1% vs 2.3%, p=0.01), and there was an increased rates in both arms for patients greater than 75 years old.
Therefore, although transfemoral CAS offers the advantage of a lower risk of MI anc CNI there is an increased risk of peri-procedural stroke risk as reflected in the CREST dats.
CEA
CAS P
CREST Peri-Procedural Stroke1
2.3%
4.1%
0.01
CREST Peri-Procedural Stroke, ≥ 75 years2
3.1%
6.9%
0.035
1N Engl J Med 2010;363: Stroke. 2011;42:00-00.

16. Comment proteger?
S macdonald : j cardiovasc surg 2010 Ballon occlusif,filtration distale,flow reverse Arrete les gros debris mais environ microparticules pendant 1 CAS protegee Ballon occlusif↓↓ hits Distal filter↑↑hits embolisation controllee Flow reverse stop hits

17. Direct Carotid Revascularization
CEA
Direct Carotid Revascularization
Transfemoral CAS
Advantages
Complete neuroprotection
Direct access
Durable
Disadvantages
More invasive, general anesthesia
Myocardial infarction risk
Cranial nerve injury
Wound complications
Potential Benefits
Neuroprotection
Minimally Invasive
Decreased Stroke Risk
Decreased MI Risk
Decreased CNI Risk
Local Anesthesia
Fast
Advantages
Minimally invasive
Local anesthesia
Durable
Disadvantages
Access-related stroke
Excess stroke risk
Asymptomatic brain infarction
Transcervical carotid revascularization is intended to reduce the respective complications of CEA and transfemoral CAS. Embolic risk is reduced by a) direct carotid access to avoid catheter manipulation in the arch and supra-aortic trunk, and b) stenting and angioplasty under high rate blood flow reversal to shunt debris of all sizes away from the brain. The use of local anesthesia and a supraclavicular mini-incision are intended to reduce the risk of MI, cranial nerve injury, and bleeding complications.

18. Flow reverse est la solution
Par abord femoral ne regle pas le probleme car l embolisation peut se produire lors de la montee du système dans la carotide primitive et lors de son retrait
Par abord trans cervical tous les problemes sont regles:
comme CAS: risque corronaire minimal
comme CEA: risque cerebral minimal

19. DW MRI Prospective Studies
Study
Procedure
Embolic Protection
# subjects
% w/ New DWI Lesions
PROFI1
Transfemoral CAS
Distal filter (Emboshield) 31
87%
ICSS2
Distal filter (various) 51
73%
Proximal occlusion (MO.MA)
45%
DESERVE3
Proximal occlusion
(MO.MA)
127
30%
PROOF
Transcervical CAS
MICHI 57
19%
CEA
Clamp, backbleed
107
17%
The incidence of new DWI lesions for transcervical CAS falls within the range of CEA.
1 J Am Coll Cardiol Jan 19 [Epub ahead of print].
2 Lancet Neurol. 2010 Apr;9(4):
3 P Rubino, 2011 EuroPCR.

20. Le flow reverse avec abord carotidien
Abord au cou sous AL Flow reverse home made Stenting sur guide 0,14

21. Pas de franchissement de la lesion sans protection Inconvenients
Avantages
Pas de navigation
Pas de franchissement de
la lesion sans protection
couts
Inconvenients
Hemodetournement cerebral
CI si calcification CP
Exposition des mains

22. 2 techniques
Custom
Silk road

23. ECHOGRAPHIE PRÉOPÉRATOIRE:
TECHNIQUE
ECHOGRAPHIE PRÉOPÉRATOIRE:

24. TECHNIQUE
INCISION:

25. DISSECTION VEINEUSE ET ARTÉRIELLE:
TECHNIQUE
DISSECTION VEINEUSE ET ARTÉRIELLE:

26. TECHNIQUE
PONCTION VEINEUSE:

27. TECHNIQUE
PONCTION VEINEUSE:

28. HÉPARINISATION SISTÉMIQUE:
TECHNIQUE
PONCTION ARTERIELLE:
HÉPARINISATION SISTÉMIQUE:

29. TECHNIQUE
CONNEXION:

30. FISTULE ARTERIO-VEINEUSE:
TECHNIQUE
FISTULE ARTERIO-VEINEUSE:

31. TECHNIQUE
PASSAGE DE LA LÉSION:

32. TECHNIQUE
LIBÉRATION DU STENT
ET BALONEMENT:

33. CONFIRMATION ARTERIOGRAPHIQUE:
TECHNIQUE
CONFIRMATION ARTERIOGRAPHIQUE:

34. SUTURE DE L’ARTÉRIOTOMIE:
TECHNIQUE
SUTURE DE L’ARTÉRIOTOMIE:

35. FERMETURE DE L’INCISION:
TECHNIQUE
FERMETURE DE L’INCISION:

36. resultats Criado : j vasc surg 2004 : 50 patients
Chang : j vasc surg : 21
Matas : j vasc surg : 62
Alvarez : j vasc surg : 81 > 80 ans
Fast cas registre : 65

37. Transcervical Carotid Revascularization With Flow Reversal In The Literature
Study
Number of Stents
Death
(30 days)
Major Stroke
Minor Stroke
Patency
Chang 2004 21
100% at 6M
Lin 2005 31 2
100% at 6M
Pippinos 2005 17
100% at 12M
Matas 2007 62
98% at 6M
Criado 2007
104
97% at 40M
Faraglia 2008 48 1
Leal 2010 35
100% at 3M
TOTAL
318
0.6%
1.6%
A new alternative which aims to addresses the challenges of both CEA and transfemoral CAS is transcervical CAS with flow reversal.
Results to date with this novel approach as reported in the literature have been very good, with a 0.6% major stroke rate at 30 days from the following series of single center experiences.
J Vasc Surg 2004;40:92-7
Criado E. VEITH 2010.

38. resultats TCMM=0 a 5% IDM= 0% Intolerance : 7%
Complication locale : 2%
HITS : 6%
Nouvelles lesions DWI :16,7%

39. Silk road 8F Transcervical Arterial Sheath
8F Venous Return Sheath
Large bore flow reversal circuit
Flow controller with stop, HI and LO flow

43. PROOF First In Man Results
Pinter L. JVS 2011;54:

44. PROOF Procedural Results
Parameter
Value (n=44)
Secondary Endpoints
Establishment of Silk Road reverse flow circuit
42 (96%)
Acute Device Success
40 (90.9%)
Procedural Success
Tolerance to reverse flow (per protocol)
41 (93%)
Investigator-reported transient intolerance
4 (9%)
Procedural Data (median ± SD)
Time on reverse flow, min
19 ± 9
Time on Hi flow, min
11 ± 6
Post procedure residual stenosis, %
7.6 ± 9.8
Volume of contrast used, cc
18.2 ± 9.9

45. PROOF Safety Results Parameter Value (n=44) Safety Endpoint
Subjects completing 30-day Follow Up
43 (97.7%)
Composite of any major stroke, myocardial infarction and death from the index procedure through the 30-day post procedural period
0 (0%)
Major Bleeding Event1
1 (2%)
Cranial Nerve Injury
DW-MRI Substudy (n=31)
Subjects with new DW-MRI lesion(s) hours post
5 (16.1%)
No strokes, death or myocardial infarction at 30 days
Major Bleeding Event: Subject developed a GI bleed / diverticulitis 2 days post procedure
1One subject developed a GI bleed 2 days post procedure

46. Conclusion Risque cerebral equivallent a CEA
Rique corronarien equivallent a CAS
Cela va-t-il reconcilier chirurgien et CAS?
Dans notre practique 10% des CAS mais a barcelone 100%
Silk road : la solution ?

50. Summary Carotid Revascularization With MICHI Neuroprotection System
The MICHI™ Neuroprotection System was shown to be a safe and feasible method for carotid revascularization
Low rate of MI and cranial nerve Injury is commensurate with transfemoral CAS and shows improvement over CEA
Low rate of stroke/death and new DWI lesions is commensurate with CEA and shows improvement over transfemoral CAS
Larger, multi-center experience is underway to confirm initial results
In summary…..

52. Atherosclerotic Aortic Lesions
Can Increase the Risk of Cerebral Embolization during CAS In Patients With Complex Aortic Arch Anatomy
N=59 Patients Undergoing CAS
In patients with all three AA characteristics, mean number and volume of embolic brain lesions was significantly greater compared with other patients.
Faggioli G. J Vasc Surg 2009;49:80-5.

53. Transcervical CAS Vs. Transfemoral CAS
“The low 12.9% incidence in the transcervical group is comparable to the best series of CEA and a great improvement over the results of CAS with distal filters.”
“The results of CAS are clearly influenced by the access route and cerebral protection methods…..The risk of embolic complications with transfemoral carotid stenting is related to instrumentation of the arch and proximal supra-aortic trunks, crossing of the carotid lesion without protection, and use of distal filter protection devices of questionable benefit.”
Leal I. JVS 2012.

56. Gupka :j vasc surg 2011
TCD 33 patients:
mean hits ipsi : 14 CAS+DF : 320
5 CAS+FR : 185
14 CEA :
Periode hits pendant pour DF
avant pour FR
apres pour CEA

58. CAS in CREST Experience & Learning Curve
Gray WA. Circulation. 2012;125:

59. CAS Procedural Evolution
2003
2010
Clair D. Cath Cardiovasc Int 77:420–429 (2011).

60. FAQ How do you manage intolerance?
Intolerance can be managed. There are many options:
Supplemental O2
Increase blood pressure
Expeditiously complete procedure and restore antegrade flow
Manage flow: intermittently switch to lo flow or stop flow
Intermittently restore antegrade flow by unclamping
In the PROOF study, 5 of 65 (7.7%) patients experienced investigator- reported intolerance. All patients successfully received a stent and intolerance resolved without clinical sequelae. Intolerance was not associated with post-procedure DWI lesions.
One of the benefits of direct carotid revascularization is the ability to perform a very quick procedure and limit the duration of CCA clamping and flow reversal (in contrast to CEA).