Direct Carotid Access for Acute Stroke Intervention Mehmet Cilingiroglu, M.D., FSCAI, FACC, FESC Mark Wholey M.D., FAHA, FSIR, FSCAI Omer Goktekin M.D., FACC, FESC University

Disclosures Funding Medtronic Inc.

What have we learned In the complex aortic arch the risk of stroke from femoral approach may not be justified IN THE CAROTID STENT CHOICE TRIAL 18% OF THE STROKES CAME FROM THE AORTIC ARCH

OCTOGENARIAN TYPE 3 ARCH May be effectively managed by trans carotid access- EMBOLIC SOURCE Vulnerable plaque

PROBLEMS of the aortic arch Complexities of the aortic arc are responsible for almost all technical failures More Trouble Ideal Trouble

Densely calcific atheromatous plaque in the aortic arch

Shower Emboli DWI Embolic stroke from atherosclerotic Arch following carotid intervention

A Need for Speed Current Tech Future Tech Begin Procedure 0 Hrs 0.5 to 1 Hrs 1.5 to 2.0 Hrs Reach the Clot Complete 0 Hrs 15 Min Begin Procedure Reach the Clot Complete Procedure 30 Min Future Tech MI Intervention time (STENTI ) vs Stroke intervention *

ADVANTAGES of TRANS CAROTID ACCESS Shorter revascularization time Shorter distance from access site to MCA /IC (only 10, 12 cm ) Smaller sheath profile (carotid Puncture with 5 or 6 fr sheath) Shorter device length. Thrombectomy and Aspiration Devices are only 30 cm long (may be more effective than longer devices) Improved torque control Improved aspiration force (Aspire) Avoids manipulation in the aortic arch Allows percutaneous closure Avoids

Case Presentation 36 year old female History of dilated cardiomyopathy On coumadin with a therapeutic INR of 2.37 Admitted to vascular surgery with acute lower extremity ischemia (ALI)mbolicevent During prep for the peripheral embolic event pt had sudden right-sided weakness Neurological exam demonstrated right-sided hemiparesis and right-sided hemianopsia Speech difficulty with slight motor aphasia and NIH score: 18

Diffusion MRI Early ischemic changes occurring in left lenticulostriate and periventricular site region

Left MCA M1 occlusion is demonstrated on the TOF – MRA images

Ultrasound for localization at C 5 site 10 cm 6 fr SHEATH in position At the common carotid and passed to the internal carotid

5fr aspiration cath ad delivery caths 25-30 cm from original length of 150 cm to 25-30 cm

Aspiration cath with tuohy completed

TOTAL OCCLUSION Lt. M 1 DISTAL TO LENTICULO STRIATES

TREVO IN CLOT POSITION AT M 1 AND PROXIMAL M 2

Post Recanalize with Aspire aspiration and thrombectomy

©Copyright CONTROL MEDICAL TECHNOLOGY

Solitaire with clot removed

Closure of Direct Carotid Access Site with Boomerang Device

Progressive timing of entire procedure 1300 Stroke Onset 1320 Neurologic Exam 1330 Imaging Exam 1340 Direct Carotid Puncture 1350 Device Aspiration & Thrombectomy 1410 Successful Reperfusion & Percutaneous Closure

Conclusion Mechanical aspiration and thrombectomy via trans carotid access may be a useful addition to the endovascular treatment for acute stroke 30 cm shortened devices are more efficient with improved aspiration and retrieval over conventional femoral approach Avoids the entire aortic arch Reduced procedure time and percutaneous closure Will require further evaluation and ultimately RCT following early feasibility studies MAT is a useful addition to other endovascular treatment modalities for acute stroke And when used as a multimodal recanalization strategy: associated with high recanalization rate, short tx time and good clinical outcome Reduce cost Obviously this is a retrospective… should be validated with future ------ Emphasize*** The aim of this sutdy was not to compare procedurla results b/w different recanalization methods