1. 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

2. Disclosures
Funding
Medtronic Inc.

3. 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

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

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

6. Densely calcific atheromatous plaque in the aortic arch

7. Shower Emboli DWI Embolic stroke from atherosclerotic
Arch following carotid intervention

8. 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 *

9. 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

10. 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

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

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

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

14. 5fr aspiration cath ad delivery caths 25-30 cm from original length of 150 cm to 25-30 cm

15. Aspiration cath with tuohy completed

16. TOTAL OCCLUSION Lt. M 1 DISTAL TO LENTICULO STRIATES

18. TREVO IN CLOT POSITION AT M 1 AND PROXIMAL M 2

19. Post Recanalize with Aspire aspiration and thrombectomy

20. ©Copyright CONTROL MEDICAL TECHNOLOGY

21. Solitaire with clot removed

22. Closure of Direct Carotid Access Site with Boomerang Device

23. 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

24. 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
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Emphasize***
The aim of this sutdy was not to compare procedurla results b/w different recanalization methods