1. Ivo Petrov MD, PhD, FESC, FACC
Novel selection criteria for CAS. Total and Subtotal Carotid Lesions: Techniques and indications
Ivo Petrov MD, PhD, FESC, FACC
Cardiology and angiology Department,
City Clinic, Sofia, Bulgaria

2. Recommendations for Selection of Patients for Carotid Revascularization (continued)
CAS is indicated as an alternative to CEA for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by more than 70% as documented by noninvasive imaging or more than 50% as documented by catheter angiography and the anticipated rate of periprocedural stroke or mortality is less than 6%. B I
IIa
IIb
III

3. Recommendations for Selection of Patients for Carotid Revascularization (continued)
It is reasonable to choose CAS over CEA when revascularization is indicated in patients with neck anatomy unfavorable for arterial surgery.§
When revascularization is indicated for patients with TIA or stroke and there are no contraindications to early revascularization, intervention within 2 weeks of the index event is reasonable rather than delaying surgery. B I
IIa
IIb
III B I
IIa
IIb
III
§Conditions that produce unfavorable neck anatomy include but are not limited to arterial stenosis distal to the second cervical vertebra or proximal (intrathoracic) arterial stenosis, previous ipsilateral CEA, contralateral vocal cord paralysis, open tracheostomy, radical surgery, and irradiation.

4. … data are still controversial.
Occlusion/ near occlusion of internal carotid arteries has long been definitive contraindication for endovascular treatment.
… but several small series showed that endovascular recanalization and stenting of occluded8 and near occluded7 carotids is feasible.
… data are still controversial.
7. Gil-Peralta A, González A, González-Marcos JR, Internal carotid artery stenting in patients with symptomatic atheromatous pseudo-occlusion, Cerebrovasc Dis. 2004;17 Suppl 1:105-12
8. M.-S. Lin, L.-C. Lin, H.-Y. Li, Procedural Safety and Potential Vascular Complication of Endovascular Recanalization for Chronic Cervical Internal Carotid Artery Occlusion, Circ Cardiovasc Intervent, October 1, 2008; 1(2):

5. Occluded/nearly occluded internal carotid arteries have lower risk of subsequent stroke, because antegrade flow no longer exists¹’²
Still, cervical ICA occlusion is associated with an annual risk of 6 to 20% of ipsilateral recurrent stroke3,4
In these cases stroke is caused more by impared perfusion, rather than by embolization 2
Fox AJ, Eliasziw M, Rothwell PM, Identificationллл . AJNR Am J Neuroradiol Sep;26(8):
Kao HL, Lin MS, Wang CS, Feasibility … J Am Coll Cardiol Feb 20;49(7):
3. Klijn CJ, van Buren PA, Kappelle LJ, et al. Outcome in patients…J Vasc Endovasc Surg 2000;19:
4. Flaherty ML, Brown Jr RD. Population-based study …Stroke 2004;35:

6. Surgical treatment : Extracranial-to-intracranial (EC-IC) artery bypass improves cerebral hemodynamics but failed to reduce the risk of ischemic stroke 5
Revascularization may be effective in a selected group of patients, in whom inadequate perfusion can be demonstrated by perfusion CT/MRI/PET 6
5. The EC-IC Bypass Study Group Failure …. N Engl J Med 1985;313:
6. Grubb Jr. RL, Derdeyn CP, Fritsch SM, et al. JAMA 1998;280:

10. First series of carotid CTO stenting

11. First report of carotid CTO stenting- 2007
Index
CTO CAS n= 30 n %
Mean age
72.1
Men 27 90
Contralateral occlusion 9 30
Primary success 22 73
In-hospital stroke 1
3.3
In-hospital mortality
Hyperperfusion or brain hemmorrhage
F-up stroke/ neurol. death

12. Procedural safety and potential vascular complications of carotid CTO recanalization
Index
CTO CAS n= 54 n %
Mean age
68.1
Primary success 35 64
In-hospital stroke 1 2
In-hospital mortality
Hyperperfusion or brain hemmorrhage
Vascular complications
Late pseudo aneur.- 1
Car-cavern fist
Minor extravas 3 6
F-up stroke/ neurol. death
18 months 4
Lin, Khao et al. Procedural safety and potential vascular complications …Circ Cardiovasc interv, Oct 2008; 1:

13. 116 pts with carotid near occlusions (out of 836)
A.González et all:
116 pts with carotid near occlusions (out of 836)
distal filter in 92 patients(79.3%).
Problems:
Frequent hypotension (37.1%),
bradycardia (48.3%), 
asystole (24.1%) .
Results:
TIA – 4 pts (3.4%)
Stroke - 1 pt (0.9%)
Follow-up months:
Restenosis - 5 patients (4.3%);
asymptomatic occlusion - 3 patients (2.6%).
Stroke - 3 patients (2.6%) , 1 ipsilateral (at 19 months) and 2 contralateral (at 6 and 30 months). 
Death from vascular cause – 7 pts (11.2%).
A. González, A. Gil-Peralta et al. Internal Carotid Artery Stenting in Patients with Near Occlusion: 30-Day and Long-Term Outcome. American Journal of Neuroradiology 32: , February 2011

14. Conclusion: Carotid near occlusion is an under-recognized condition, and CAS seems to be beneficial when performed by an experienced neurointerventional team.
A. González, A. Gil-Peralta et al. Internal Carotid Artery Stenting in Patients with Near Occlusion: 30-Day and Long-Term Outcome. American Journal of Neuroradiology 32: , February 2011

15. Proximal cerebral protection in all but 1 patient.
Nikas et al:
A retrospective analysis of 25 patiens who underwent carotid stenting for string sign carotid lesions.
 Proximal cerebral protection in all but 1 patient.
No neurological events at 30 days and at 12 months follow up.
Conclusion: ”Carotid stenting under proximal cerebral protection seems to be a feasible and safe procedure to manage patients with severe carotid stenosis in presence of angiographic string sign.”
Nikas, Stabile, Reimers et al. Carotid Artery Stenting With Proximal Cerebral Protection for Patients With Angiographic Appearance of String Sign; J Am Coll Cardiol Intv, 2010; 3: ,

16. (1) J. Yadav in an editorial comment on JACC:
The decision to revascularize a patient with a carotid string sign remains complex and should be made after careful deliberation.
These patients seem to have a lower risk of stroke most likely due to diminished antegrade flow and the presence of collateral circulation.
Most of these patients, particularly asymptomatic patients, do not require revascularization. Therapy, however, should be tailored to the individual patient.
Recurrent or crescendo symptoms warrant treatment.
EDITORIAL COMMENT: Functional Occlusions of the Carotid Artery (String Signs) To Treat or Not to Treat? Jay S. Yadav, MD. Atlanta, Georgia
V O L . 3 , N O . 3 , ; I S S N / 1 0 / $ ; D O I : / j . j c i n

17. (2)
Stable or asymptomatic patients who demonstrate a reversible perfusion defect on stress perfusion testing with SPECT, MRI or CT might also benefit from revascularization .
Recurrent symptoms or a reversible perfusion defect are required before intervention is considered in patients with functional occlusion of the carotid artery.
Symptomatic patients with thrombus are best treated by endarterectomy. Asymptomatic patients with thrombus should also be offered surgery if they are suitable candidates;
In patients with string signs requiring carotid stenting, proximal protection is a useful technique and might be preferable to filter-based devices, if the aortic arch and common carotid anatomy are suitable.
EDITORIAL COMMENT: Functional Occlusions of the Carotid Artery (String Signs) To Treat or Not to Treat? Jay S. Yadav, MD. Atlanta, Georgia
V O L . 3 , N O . 3 , ; I S S N / 1 0 / $ ; D O I : / j . j c i n

18. 10 pts with extracranial occlusion > 3 months:
6 pts – stenting of CA occl.
4 pts – stenting of VA occl.
All with flow-reversal technique
Criteria for stenting:
Hemodynamic stroke/TIA/transient symptoms
Complete occlusion
Lesion limited in the cervical area
All pts > 1 year clinical and angiographic follow up
Successful recanalization in all 10 pts
No complications during the periprocedural period.
Neither transient ischemic events nor restenosis during the follow-up period.

19. Our experience with stenting of Occluded and Nearly Occluded Carotid Arteries
Retrospective analysis of the procedural results and midterm follow-up of the stenting of 53 chronically occluded/nearly occluded carotid arteries – 11% of the total 453 consecutive carotid stentitng procedures, which were carried out between 2006 and 2012.

20. Stenting of Occluded and Nearly Occluded Carotid Arteries – Anatomical Criteria:
True occlusion: 6 lesions (12%)
Discontinuation of ICA lumen
TIMI antegrade flow grade 0 distal to the occlusion
Established collateral filling to the ipsilateral intracranial ICA territory
Near occlusion*: 47 lesions (88%)
Delayed cranial arrival of ICA contrast compared with external carotid artery (ECA);
Intracranial collaterals seen as cross-filling of contralateral vessels or ipsilateral contrast dilution
Obvious diameter reduction of distal ICA compared with opposite ICA
ICA diameter reduction compared with ipsilateral ECA
* Alan J Fox. Identification, Prognosis, and Management ofPatients with Carotid Artery Near Occlusion. AJNR Am J Neuroradiol 26:2086–2094, September 2005

21. Stenting of Occluded and Nearly Occluded Carotid Arteries – Clinical Inclusion Criteria:
Clinical and Duplex scan data of chronic (more than 3 months) ICA occlusion.
History of neurological symptoms related to the chronic carotid occlusion
Recurrence of neurologic symptoms in the last 3 months (recurrent CVA or TIA) or:
CT, MRI proven new zones of cerebral ischemia / infarction in the time window between the target carotid occlusion and endovascular procedure

22. Stenting of Occluded and Nearly Occluded Carotid Arteries Demographic data:
Index
CAS n= 53 n %
Males 42 80
Mean age
65 (51-80)
Diabetics 15 30
Hypertension 50 94
Dyslipidemia 56
Smoking 29 54

23. Stenting of Occluded and Nearly Occluded Carotid Arteries Preprocedural symptomatic status and indications:
Pre-procedure conditions n %
Prior ipsilateral stroke 33 62
Ipsilateral TIA 20 37
Contralateral ICA stenosis >50% 14 26
Progression of neurologic deficit after known ICA occlusion , or new silent strokes on the MRI, CT scan 53
100

24. 0.014 “Asahi Miracle” or “Confianza” 7 13 Microcatheters 10 19
Stenting of Occluded and Nearly Occluded Carotid Arteries Technical and intraprocedural characteristics ( Mainly coronary CTO techniques and materials used)
Index
CAS n= 53 n %
0.014 Hydrophilic wires 46 88
“Asahi Miracle” or “Confianza” 7 13
Microcatheters 10 19
EPD used 51 96
Filter EPD
Predilation before filter insertion
*Undersized mm coronary balloon
14* 26
Reversal of flow EPD 1 2
Nitinol stents implanted
* 3pts x 2 stents implanted
55*

25. Stenting of Occluded and Nearly Occluded Carotid Arteries – Results: Technical success%
 Successful wire crossing and recanalization 52 98
Successful distal EPD placement
*1 failed filter introduction (extreme distal tortusity)
51* 96
Residual stenosis ≤ 20%
*2 cases 50-60% resid. stenosis(extreme circular calcification)
50* 94
Successful TIMI-3 flow restoration in the main vessel 49 92
 Ipsilateral hemisphere circulation restoration 48 91
 Target vessel complication
*1 local vessel dissection with no clinical significance 1* 2

26. Stenting of Occluded / Nearly Occluded Carotid Arteries – Results: Clinical success%
  Ipsilateral Stroke
* 1 early acute stent thrombosis- recanalized with Abciximab infus. and ballooning 1*
1.9
Death
*1 cardiogenic shock
Myocardial infarction 1
Stroke/death/MI 2
3.9
TIA
Hyperperfusion syndrome
 Vascular access complications
*1 Premature ambulation hematoma
 Severe bradicardia and hypotension requiring inotropes

27. In-hospital outcomes. Comparison between Carotid CTO CAS and Global population CAS
Index
CAS CTO n=53
CAS no CTO n= 181
P Value
Ipsilateral stroke 1
1.9% 3
1.6% ns
AMI 2
1.1%
Death 0%
ТIA 4
2.2%
Stroke/death/MI
3.8% 5
2.7% ns

28. Stenting of Occluded and Nearly Occluded Carotid Arteries – Clinical and Duplex Follow-up (18months): n %
 Followed for 3 mo 50
100
Follow-up 18 months: 41 82
 Ipsilateral stroke
* Patient with not fully restored cerebral flow and presence of contralateral h. grade stenosis 1* 2
TIA
 Death
* Not related (Lung cancer)
Stent deformation/crush
 Restenosis> 50%
* 1 of 2 underexpanded stents(asymptomatic)

29. CAD – single vessel disease, stable AP.
Clinical Case Stenting of a subtotal occlusion of the left internal carotid artery with a total occlusion of the right internal carotid artery
70-year-old male
CAD – single vessel disease, stable AP.
History of two strokes in the last 1 year(the latest 1 mo before procedure)
Chronic total occlusion of the right internal carotid artery, subtotal of the left ICA 29

30. Case report - Occlusion of LICA with a “filiform” distal blood flow – “string sign”30

31. Case report - Positionning of the EPD Emboshield 5.031

32. Protégé 10-7/40 implantation and postdilation with 5
Protégé 10-7/40 implantation and postdilation with 5.0/20mm Muso Balloon

33. Case report - Final result
Uneventful 3 y.f-up 33

34. 66 year-old man
Multifocal atherosclerosis: PAD – history of the right foreleg amputation (2008) and critical ischemia of the left food, also scheduled for amputation.
Three months ago – PTA of left SF and left tibioperoneal trunk , followed by limb salvage and complete healing of the ulcers.
One month ago – stenting of 75% LICA stenosis and unsuccessful attempt for recanalization of a totally occluded RICA.

35. The procedure of the left lower limb1) 2)

36. RICA – chronic thrombosis with neovascularization and partially restored distal flow

37. The occlusion was overcome with a Pilot 200 hydrophilic guidewire and a Fine Cross microcatheter – a technique “dedicated” to coronary CTOs

38. Predilation over the 0. 014” guidewire with a 2
Predilation over the 0.014” guidewire with a 2.0/20 mm balloon, and after the positioning of the distal filter (Spider 5.0), another predilatation with 4.0/20 mm balloon

39. Stent implantation – taperred stent Protégé 10-7/40 mm

40. Postdilatation with a 5.0/20 mm balloon

41. Final result

42. Bilateral carotid recanalization by radial approach in a patient with Lerich syndrome
1. Subtotal RICA stenosis stenting

43. Radial access in Lerich for CAS
2. Subtotal LICA stenosis stenting. Radial approach 6Fr GC JR 4.0

44. Radial access – wire crossing

45. Radial access - predilation
Da se smeni filma

46. Radial access – stent deployment (Cristallo Idealle)

47. Radial access – postdilatation
Trqbva film

48. Radial access – final result

49. Conclusions:
Endovascular recanalization of occluded/near occluded carotid arteries is feasible and safe procedure
This procedure has to be carried on a very selective group of patients showing clinical and instrumental signs of recurrent cerebral ischemia
The late preventive role and benefit of the method has to be proven in larger studies

50. Thank you for your attention