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Cardiology
Carotid and Vertebral Artery Interventions Extra-Cranial Cerebrovascular Interventions
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
9 sections · 107 slides
Burden and rationale
- Stroke burden and carotid atherosclerosis
- Scope of extra-cranial cerebrovascular intervention
Carotid intervention: the evidence
- Endarterectomy as the established benchmark
- SAPPHIRE: stenting in the high surgical risk patient
- CREST 10-year results
- ACST-2 in standard surgical risk patients
- ACT I and CREST-2
- Regulatory and guideline position
- Landmark carotid stenting trials
- Landmark carotid stenting trials: design and protection use
- Landmark carotid stenting trials: death
- Landmark carotid stenting trials: stroke
- Landmark carotid stenting trials: periprocedural myocardial infarction
Indications and patient selection
- Procedural risk thresholds for carotid stenting
- Current societal guidelines on CAS by symptoms and degree of stenosis
- High surgical risk criteria used in SAPPHIRE
- Anatomical high surgical risk criteria
- NCDR C1A2S3 risk score from the CARE registry
- Mechanisms behind the age penalty in stenting
- Additional clinical factors in modality choice
- Aortic arch classification
- Aortic arch types by great-vessel origin
- Type III arch and procedural risk
- Aortic arch branching patterns and the misnamed bovine arch
- Bovine arch variant and access planning
- Anatomical features that disfavour transfemoral or transradial CAS
- Tortuosity and lesion characteristics
Access and diagnostic angiography
- Transfemoral versus transradial access
- Anatomical subgroups favouring right radial access
- Radiation, procedure time and cost with radial access
- Procedural anticoagulation and transcarotid revascularisation
- Non-selective aortic arch angiography
- Wire selection for great-vessel navigation
- Non-stiff hydrophilic wires and their hazards
- Diagnostic catheters used for cerebral angiography
- Catheter selection by aortic arch type
- Catheter shaft properties and their trade-offs
Equipment delivery and stenting
- Sequence of carotid artery stenting
- Exchange technique and sheath placement
- Avoiding embolisation during sheath advancement
- Catheter telescoping for a difficult common carotid
- Carotid stent designs
- Open-cell versus closed-cell stent outcomes
- Second-generation dual-layered carotid stents
- Predilatation of the carotid lesion
- Stent placement and post-dilatation
Embolic protection
- Evidence for embolic protection devices
- Types of embolic protection device
- Distal filter versus proximal flow diversion
- Advantages and disadvantages of different embolisation protection devices
- Clinical and anatomic factors favouring type of embolic protection device
Haemodynamic monitoring and complications
- Carotid baroreceptor response during stenting
- Management of periprocedural haemodynamic instability
- Antiplatelet therapy and follow-up after CAS
- Overview of carotid stenting complications
- Proximal cervical complications
- Distal cervical and intracranial complications
- Cerebral macroembolisation and hyperperfusion syndrome
Vertebral artery interventions
- Why asymptomatic vertebral stenosis is not treated
- Mechanistic categorisation of the ischaemic event
- Thresholds for vertebral artery revascularisation
- Access for vertebral artery intervention
- Catheter shapes for vertebral angiography and support
- Optimising support and equipment delivery
- Direct stenting versus predilatation in the vertebral artery
- Anatomical segments of the vertebral artery
- Vertebral artery segments and interventional suitability
- V1 ostial disease and stent fracture
- Drug-coated balloon angioplasty in the vertebral artery
- V3 and V4 segments: why intervention is avoided
- Intracranial vertebral segment and surgical alternatives
- Embolic risk during vertebral artery intervention
- Balloon inflation and deflation sequence for embolic protection
- Methods of embolic protection in vertebral intervention
- Procedural success of vertebral artery stenting
- Vertebral artery stenting outcome series
- Outcomes of vertebral artery stenting trials
- Outcomes of vertebral artery stenting trials (continued)
- Bare metal versus drug-eluting stents in vertebral stenosis
- Self-expanding stents and choice against surgery
- Complications of vertebral artery intervention
- Complications of surgical vertebral reconstruction
Summary
- Key numbers
- Carotid intervention takeaways
- Vertebral intervention takeaways
- Conclusion
- References
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- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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