Une technique simple ? Pour les cas difficiles ? JM CARDON Hopital prive les franciscaines nimes.
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Transcript of Une technique simple ? Pour les cas difficiles ? JM CARDON Hopital prive les franciscaines nimes.
Le stenting carotidien par voie cervicale
Une technique simple ?
Pour les cas difficiles ?
JM CARDON
Hopital prive les franciscaines nimes
Criteres cliniques : AVC
Eva 3s Ipsi+contro 9,6% 527 2000/2005
SPACE IPSI 6,4% 1183 2001/2006
ICSS Ipsi+contro 7,4% 1713 2005/2010
CREST Ipsi+contro 4,1% 2522 2006/2011
RISQUE CLINIQUE CAS
RISQUE CEREBRAL CAS
criteres anatomiques
ICSS sub study124 CAS avec IRM pre/post Transfemoral+filtre distal
50% nouvelles lesions ischemiques
CASRISQUE ANATOMIQUE
1363 CAS 754 CEA
Nouvelle lesion IRM
37%
Nouvelle lesion IRM
10%
Metaanalyse KARSTRUP STROKE 2008 IRM PRE ET POST CAS /CEA
RISQUE CEREBRAL A LA NAVIGATIONQUEL TERRITOIRE ?
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%
Grossetti : acta chir belg 201150 CAS: pas de predilatation ;filtre distalHR color flow mappingTCD intra op + 12 H post opDWI pre/post4 test psycometriquesAudit neuro
QUEL RISQUE A CAS ?
Minor stroke : 4% hits per op : 100% Hits post op : 10% Nouvelles lesions ischemiques : 44% Diminution capacites cognitives : 36%
Confidential
DW MRICLINICAL SIGNIFICANCE OF NEW WHITE LESIONS
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.
DW MRICLINICAL SIGNIFICANCE OF WHITE LESIONS
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.
En consequencependant cas
IL EXISTE UN RISQUE CLINIQUE ET ANATOMIQUE
LES HITS ( embol) ONT UNE CONSEQUENCE ANATOMIQUE:PETIRES LESIONS ISCHEMIQUES A L’IRM
MEME SI PAS D’AVC :DIMINUTION DES FONCTIONS COGNITIVES
Patients a risque pour la navigation
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
Patient a risque pour la navigation:lesion emboligene
Crosse aortique : calcification debris atheromateux thrombus
Bifurcation carotidienneGros amas calcaireTrombusHemmoragie intraplaque
Lesions tandem
Patient a risque pour la navigation
age
Meta analyse Bonati :eur j vasc 2011 eva3s space icss : 3433 patientsTCMM a 120 jours : 8,9% age seul subgroup significatif: age<70 ans:5,8% age>70 ans:12%
Il existe donc un risque a la navigation
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
Transfemoral CASLow risk of MI and CNI but increased peri-procedural stroke risk
CEA CAS P
CREST Peri-Procedural Stroke1 2.3% 4.1% 0.01
CREST Peri-Procedural Stroke, ≥ 75 years2 3.1% 6.9% 0.035
1N Engl J Med 2010;363:11-23. 2 Stroke. 2011;42:00-00.
Comment proteger?
S macdonald : j cardiovasc surg 2010Ballon occlusif,filtration distale,flow reverse Arrete les gros debris mais environ 100 000
microparticules pendant 1 CAS protegeeBallon occlusif↓↓ hitsDistal filter↑↑hits embolisation
controlleeFlow reverse stop hits
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
NeuroprotectionMinimally Invasive
Decreased Stroke RiskDecreased MI RiskDecreased CNI RiskLocal Anesthesia
Fast
Direct Carotid Revascularization
Flow reverse est la solution
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 minimalcomme CEA: risque cerebral minimal
Study Procedure Embolic Protection
# subjects % w/ New DWI Lesions
PROFI1 Transfemoral CAS
Distal filter (Emboshield) 31 87%
ICSS2 Transfemoral CAS Distal filter (various) 51 73%
PROFI1 Transfemoral CAS
Proximal occlusion (MO.MA) 31 45%
DESERVE3 Transfemoral CAS
Proximal occlusion(MO.MA) 127 30%
PROOF Transcervical CAS MICHI 57 19%
ICSS2 CEA Clamp, backbleed 107 17%
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.
DW MRIProspective Studies
Le flow reverse avec abord carotidien
Abord au cou sous AL
Flow reverse home made
Stenting sur guide 0,14
Avantages
Pas de navigation
Pas de franchissement de
la lesion sans protection
couts
Inconvenients
Hemodetournement cerebral
CI si calcification CP
Exposition des mains
2 techniques
Custom
Silk road
TECHNIQUE
ECHOGRAPHIE PRÉOPÉRATOIRE:
TECHNIQUE
INCISION:
TECHNIQUE
DISSECTION VEINEUSE ET ARTÉRIELLE:
TECHNIQUE
PONCTION VEINEUSE:
TECHNIQUE
PONCTION VEINEUSE:
TECHNIQUE
PONCTION ARTERIELLE:
HÉPARINISATION SISTÉMIQUE:
TECHNIQUE
CONNEXION:
TECHNIQUE
FISTULE ARTERIO-VEINEUSE:
TECHNIQUE
PASSAGE DE LA LÉSION:
TECHNIQUE
LIBÉRATION DU STENTET BALONEMENT:
TECHNIQUE
CONFIRMATION ARTERIOGRAPHIQUE:
TECHNIQUE
SUTURE DE L’ARTÉRIOTOMIE:
TECHNIQUE
FERMETURE DE L’INCISION:
resultats 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
Criado E. VEITH 2010.J Vasc Surg 2004;40:92-7
Study Number of Stents
Death(30 days)
Major Stroke
(30 days)
Minor Stroke
(30 days)
Patency
Chang 2004 21 0 0 0 100% at 6M
Lin 2005 31 0 0 2 100% at 6M
Pippinos 2005 17 0 0 0 100% at 12M
Matas 2007 62 0 2 0 98% at 6M
Criado 2007 104 0 0 2 97% at 40M
Faraglia 2008 48 0 0 1 100% at 6M
Leal 2010 35 0 0 0 100% at 3M
TOTAL 318 0 0.6% 1.6%
Transcervical Carotid RevascularizationWith Flow Reversal In The Literature
resultats
TCMM=0 a 5% IDM= 0% Intolerance : 7% Complication locale : 2% HITS : 6% Nouvelles lesions DWI :16,7%
Silk road 8F Transcervical Arterial Sheath 8F Venous Return Sheath
Large bore flow reversal circuit Flow controller with stop, HI and LO flow
PROOFFIRST IN MAN RESULTS
Pinter L. JVS 2011;54:1317-23.
44
Parameter Value (n=44)
Secondary Endpoints
Establishment of Silk Road reverse flow circuit 42 (96%)
Acute Device Success 40 (90.9%)
Procedural Success 40 (90.9%)
Tolerance to reverse flow (per protocol) 41 (93%)
Investigator-reported transient intolerance 4 (9%)
Procedural Data (median ± SD)
Time on reverse flow, min 19 ± 9
Time on Hi flow, min 11 ± 6
Post procedure residual stenosis, % 7.6 ± 9.8
Volume of contrast used, cc 18.2 ± 9.9
PROOFProcedural Results
Parameter Value (n=44)
Safety Endpoint
Subjects completing 30-day Follow Up 43 (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 Event1 1 (2%)
Cranial Nerve Injury 0 (0%)
DW-MRI Substudy (n=31)
Subjects with new DW-MRI lesion(s) 24-72 hours post 5 (16.1%)
1One subject developed a GI bleed 2 days post procedure
PROOFSafety Results
Conclusion
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 ?
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
SummaryCarotid Revascularization With MICHI Neuroprotection System
Atherosclerotic Aortic Lesions
Faggioli G. J Vasc Surg 2009;49:80-5.
CAN INCREASE THE RISK OF CEREBRAL EMBOLIZATION DURING CAS IN PATIENTS WITH COMPLEX AORTIC ARCH ANATOMY
52
In patients with all three AA characteristics, mean number and volume of embolic brain lesions was significantly greater compared with other patients.
28.8%35.5%
57.6%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Difficult Arch ComplicatedAortic Plaque
Tortuosity Index>150*
N=59 Patients Undergoing
CAS
ConfidentialLeal I. JVS 2012.
53
TRANSCERVICAL CASVS. TRANSFEMORAL 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.”
Gupka :j vasc surg 2011TCD 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
Confidential
CAS IN CREST
Gray WA. Circulation. 2012;125:2256-2264
EXPERIENCE & LEARNING CURVE
58
Confidential
Clair D. Cath Cardiovasc Int 77:420–429 (2011).
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
Stroke/death
2003 2010
CASPROCEDURAL EVOLUTION
Confidential
FAQHOW DO YOU MANAGE INTOLERANCE?
Intolerance can be managed. There are many options:
1. Supplemental O2
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).