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Une technique simple ? Pour les cas difficiles ? JM CARDON Hopital prive les franciscaines nimes.

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Presentation on theme: "Une technique simple ? Pour les cas difficiles ? JM CARDON Hopital prive les franciscaines nimes."— Presentation transcript:

1 Une technique simple ? Pour les cas difficiles ? JM CARDON Hopital prive les franciscaines nimes

2 Criteres cliniques : AVC Eva 3sIpsi+contro9,6%5272000/2005 SPACEIPSI6,4%11832001/2006 ICSSIpsi+contro7,4%17132005/2010 CRESTIpsi+contro4,1%25222006/2011

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

4 1363 CAS754 CEA Nouvelle lesion IRM 37% Nouvelle lesion IRM 10% Metaanalyse KARSTRUP STROKE 2008 IRM PRE ET POST CAS /CEA

5 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 Grossetti : acta chir belg 2011 50 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 Confidential DW MRI C LINICAL S IGNIFICANCE OF N EW W HITE L ESIONS 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 C LINICAL S IGNIFICANCE OF W HITE L ESIONS 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 IL EXISTE UN RISQUE CLINIQUE ET ANATOMIQUE LES HITS ( embol) ONT UNE CONSEQUENCE ANATOMIQUE:PETIRES LESIONS ISCHEMIQUES A LIRM MEME SI PAS DAVC :DIMINUTION DES FONCTIONS COGNITIVES

11 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 Crosse aortique : calcification debris atheromateux thrombus Bifurcation carotidienne Gros amas calcaire Trombus Hemmoragie intraplaque Lesions tandem

13 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 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 CEACASP CREST Peri-Procedural Stroke 1 2.3%4.1%0.01 CREST Peri-Procedural Stroke, 75 years 2 3.1%6.9%0.035 1 N Engl J Med 2010;363:11-23. 2 Stroke. 2011;42:00-00.

16 S macdonald : j cardiovasc surg 2010 Ballon occlusif,filtration distale,flow reverse Arrete les gros debris mais environ 100 000 microparticules pendant 1 CAS protegee Ballon occlusif hits Distal filterhits embolisation controllee Flow reverse stop hits

17 Confidential Advantages – Minimally invasive – Local anesthesia – Durable Disadvantages – Access-related stroke – Excess stroke risk – Asymptomatic brain infarction Advantages – Complete neuroprotection – Direct access – Durable Disadvantages – More invasive, general anesthesia – Myocardial infarction risk – Cranial nerve injury – Wound complications CEA Transfemoral CAS Potential Benefits Neuroprotection Minimally Invasive Decreased Stroke Risk Decreased MI Risk Decreased CNI Risk Local Anesthesia Fast Potential Benefits Neuroprotection Minimally Invasive Decreased Stroke Risk Decreased MI Risk Decreased CNI Risk Local Anesthesia Fast Direct Carotid Revascularization

18 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 StudyProcedureEmbolic Protection # subjects% w/ New DWI Lesions PROFI 1 Transfemoral CAS Distal filter (Emboshield) 3187% ICSS 2 Transfemoral CAS Distal filter (various)5173% PROFI 1 Transfemoral CAS Proximal occlusion (MO.MA) 3145% DESERVE 3 Transfemoral CAS Proximal occlusion (MO.MA) 12730% PROOF Transcervical CAS MICHI5719% ICSS 2 CEAClamp, backbleed10717% 1 J Am Coll Cardiol. 2012 Jan 19 [Epub ahead of print]. 2 Lancet Neurol. 2010 Apr;9(4):353-62. 3 P Rubino, 2011 EuroPCR.

20 Abord au cou sous AL Flow reverse home made Stenting sur guide 0,14

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

22 Custom Silk road

23 TECHNIQUE ECHOGRAPHIE PRÉOPÉRATOIRE:

24 TECHNIQUE INCISION:

25 TECHNIQUE DISSECTION VEINEUSE ET ARTÉRIELLE:

26 TECHNIQUE PONCTION VEINEUSE:

27 TECHNIQUE

28 TECHNIQUE PONCTION ARTERIELLE: HÉPARINISATION SISTÉMIQUE:

29 TECHNIQUE CONNEXION:

30 TECHNIQUE FISTULE ARTERIO-VEINEUSE:

31 TECHNIQUE PASSAGE DE LA LÉSION:

32 TECHNIQUE LIBÉRATION DU STENT ET BALONEMENT:

33 TECHNIQUE CONFIRMATION ARTERIOGRAPHIQUE:

34 TECHNIQUE SUTURE DE LARTÉRIOTOMIE:

35 TECHNIQUE FERMETURE DE LINCISION:

36 Criado : j vasc surg 2004 : 50 patients Chang : j vasc surg 2004 : 21 Matas : j vasc surg 2007 : 62 Alvarez : j vasc surg 2008 : 81 > 80 ans Fast cas registre : 65

37 Criado E. VEITH 2010.J Vasc Surg 2004;40:92-7 StudyNumber of Stents Death (30 days) Major Stroke (30 days) Minor Stroke (30 days) Patency Chang 200421000100% at 6M Lin 200531002100% at 6M Pippinos 200517000100% at 12M Matas 20076202098% at 6M Criado 200710400297% at 40M Faraglia 200848001100% at 6M Leal 201035000100% at 3M TOTAL31800.6%1.6%

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

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

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43 PROOF F IRST I N M AN R ESULTS Pinter L. JVS 2011;54:1317-23.

44 44 ParameterValue (n=44) Secondary Endpoints Establishment of Silk Road reverse flow circuit42 (96%) Acute Device Success40 (90.9%) Procedural Success40 (90.9%) Tolerance to reverse flow (per protocol)41 (93%) Investigator-reported transient intolerance4 (9%) Procedural Data (median ± SD) Time on reverse flow, min19 ± 9 Time on Hi flow, min11 ± 6 Post procedure residual stenosis, %7.6 ± 9.8 Volume of contrast used, cc18.2 ± 9.9

45 ParameterValue (n=44) Safety Endpoint Subjects completing 30-day Follow Up43 (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 Event 1 1 (2%) Cranial Nerve Injury0 (0%) DW-MRI Substudy (n=31) Subjects with new DW-MRI lesion(s) 24-72 hours post5 (16.1%) 1 One subject developed a GI bleed 2 days post procedure

46 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 ?

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50 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

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52 Faggioli G. J Vasc Surg 2009;49:80-5. C AN I NCREASE THE R ISK OF C EREBRAL E MBOLIZATION DURING CAS I N P ATIENTS W ITH C OMPLEX A ORTIC A RCH A NATOMY 52 In patients with all three AA characteristics, mean number and volume of embolic brain lesions was significantly greater compared with other patients. N=59 Patients Undergoing CAS

53 Confidential Leal I. JVS 2012. 53 T RANSCERVICAL CAS V S. T RANSFEMORAL 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.

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56 Gupka :j vasc surg 2011 TCD 33 patients: mean hits ipsi : 14 CAS+DF : 320 5 CAS+FR : 185 14 CEA : 15 Periode hits pendant pour DF avant pour FR apres pour CEA

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58 Confidential CAS IN CREST Gray WA. Circulation. 2012;125:2256-2264 E XPERIENCE & L EARNING C URVE 58

59 Confidential Clair D. Cath Cardiovasc Int 77:420–429 (2011). 2003 2010 CAS P ROCEDURAL E VOLUTION

60 Confidential FAQ H OW DO YOU MANAGE INTOLERANCE ? Intolerance can be managed. There are many options: 1.Supplemental O 2 2.Increase blood pressure 3.Expeditiously complete procedure and restore antegrade flow 4.Manage flow: intermittently switch to lo flow or stop flow 5.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).

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