1. Endovascular treatment on tandem lesions of cranial arteries Xiao-Long Zhang, MD, PhD Department of Radiology Huashan Hospital,Fudan University Shanghai ， China

2. Objective To evaluate the technical and clinical outcomes of patients with symptomatic atherosclerotic tandem lesions of CCA ， ICA, MCA, ACA after elective stent placement. To evaluate the technical and clinical outcomes of patients with symptomatic atherosclerotic tandem lesions of CCA ， ICA, MCA, ACA after elective stent placement.

3. Materials From Jan. 2006 to Aug.2009 From Jan. 2006 to Aug.2009 9 patients (1 Females and 8 Males) 9 patients (1 Females and 8 Males) Average age 63 (52-70) Average age 63 (52-70) Vessels involved ： CCA ， ICA ， MCA ， ACA ， VA ， BA, Vessels involved ： CCA ， ICA ， MCA ， ACA ， VA ， BA, 18 tandem lesions were treated by implantation of stents 18 tandem lesions were treated by implantation of stents Average clinical follow up of all patients were 11.3 months (5-24) Average clinical follow up of all patients were 11.3 months (5-24) Four patients accept angiography after 6 months follow up Four patients accept angiography after 6 months follow up

4. Tandem lesions: 9 cases Proximal component Distal component Cases Cervical ICA Intracranial ICA or MCA 4 CCA Cervical ICA 2 Cervical VA Intracranial VA 3

5. Results 9 cases including 18 tandem lesions treated by stent implantation were all technically successful. 9 cases including 18 tandem lesions treated by stent implantation were all technically successful. All patients were free from stoke recurrence in the follow-up and no severe complications and/or deaths were related to the treatment. All patients were free from stoke recurrence in the follow-up and no severe complications and/or deaths were related to the treatment. Angiography of 1 patient showed in stent restenosis after 6 months followup Angiography of 1 patient showed in stent restenosis after 6 months followup

6. Questions 1.Whether the patient should be treated by endovascular therapy? 1.Whether the patient should be treated by endovascular therapy? 2.Proximal and distal lesions, which should be treated first? 2.Proximal and distal lesions, which should be treated first? 3.Should all lesions be treated at the same time or by staged procedure? 3.Should all lesions be treated at the same time or by staged procedure?

7. 1.Whether the patient should be treated by endovascular therapy? All patients have clinically lesion- related CI/TIA. All patients have clinically lesion- related CI/TIA. If left untreated, the lesions will result in untoward outcome such as stroke and death according to introcranial hemodynamic analysis. If left untreated, the lesions will result in untoward outcome such as stroke and death according to introcranial hemodynamic analysis. The treatment procedural should be possible and low risk according to operators evaluation and experience The treatment procedural should be possible and low risk according to operators evaluation and experience

8. 2.Proximal and distal component, which should be treated first? 1) Tandem lesions in ICA/MCA: The distal lesion is to be treated first in most cases due to its higher risk (If the stent implantation of distal lesion is failed, the treatment of the proximal one maybe unnecessary, unless the ICA lesion effect the guiding plant and may result in embolic event). (If the stent implantation of distal lesion is failed, the treatment of the proximal one maybe unnecessary, unless the ICA lesion effect the guiding plant and may result in embolic event). 2) Tandem lesions in VA: The distal lesion is to be treated first (possibility of stent migration).

9. 2.1 The situation we should handle the proximal lesion first: severe stenosis or unstable plaque of proximal lesion (The lesion in the proximal part will affect the stent implantation of distal part and the risk of the plaque detachment in the proximal lesion during the stent implantation of distal part will be higher).

10. 3.Should all lesions be treated at the same time or by staged procedure? 1.Treatment method may differ depending on patient ’ s condition, surgeons ’ experience. 1.Treatment method may differ depending on patient ’ s condition, surgeons ’ experience. 2.Staged treatment is preferred if the patient can not tolerant the complex procedure for a long duration. 2.Staged treatment is preferred if the patient can not tolerant the complex procedure for a long duration.

11. 4.How to deal with incidental lesions such as an aneurysm? Aneurysms should always be treated first due to its high incidence of death when ruptured and the sucessful treatment of aneurysms is essential for antiplatelet therapy after stent implantation. Aneurysms should always be treated first due to its high incidence of death when ruptured and the sucessful treatment of aneurysms is essential for antiplatelet therapy after stent implantation.

12. Case Presentations

13. Case 1 Male, 68y/o Male, 68y/o Vertigo for two months Vertigo for two months History of DM and Hypertension History of DM and Hypertension Cerebral ischemia Cerebral ischemia

14. Occlusion of R ICA ， Stenosis of L CCA and L ICA

16. Treatment strategy Proximal and distal component, which one to be treated first? Proximal and distal component, which one to be treated first? Size of Guiding catheter? Size of Guiding catheter? Kinds of protective device and how to retrieve it safely? Kinds of protective device and how to retrieve it safely?

17. Distal ： 6F guiding,Spider ， PTA distal and proximal 6*20 ， and 8F guiding with 0.35 wire, Prot é g é 8*40 Proximal ： Spider ， Prot é g é 8*40 5F catheter assistant

18. Case 2 Male, 60 y/o Male, 60 y/o Weakness of left limbs Weakness of left limbs History of hypertension and hyperlipidemia History of hypertension and hyperlipidemia

19. Stenosis: Bilateral VA, initial part of R PICA, L MCA(M1), L ACA(A1) Stenosis: Bilateral VA, initial part of R PICA, L MCA(M1), L ACA(A1) Occlusion: R ICA Occlusion: R ICA

20. R PICA Gateway2*15 L VA Gateway 3*15 Wingspan3.5*15

21. ACA Gateway2.5*9 MCA Gateway3*9 Wingspan 3.5*9

22. Case 3 Female ， 70 y/o Female ， 70 y/o Stenosis of proximal cervical L ICA and C2 segment of L ICA Stenosis of proximal cervical L ICA and C2 segment of L ICA Stenosis of R VA origin Stenosis of R VA origin Aneurysm on C2 segment of L ICA Aneurysm on C2 segment of L ICA

23. Treatment Strategy for Case 3 The patient was treated twice The patient was treated twice 1.Tandem lesion including stenosis in proximal cervical L ICA and C2 segment of L ICA accompanied with an aneurysm were treated under general anesthesia.

24. 1. Proximal cervical ICA: Spider RX, Prot é g é 7*30 2. C2: Stenosis-Wingspan 4.5*15 ， AN-coils

25. 2.Two weeks later the patient receive the second treatment under local anesthesia. RVA:SpiderRX,Gateway4*9,Wingspan4. 5*20

26. Conclusion Endovascular therapy of tandem lesions is complex, especially the choice of treatment strategy. Endovascular therapy of tandem lesions is complex, especially the choice of treatment strategy. Patient specific interventional strategy is achievable by balancing the risk and the benefit of the treatment. Patient specific interventional strategy is achievable by balancing the risk and the benefit of the treatment.

27. Thank you!