SIR-RFS Webinar (2/27/2018): Neuro Interventional Radiology: Carotid Artery Stenting

SIR-RFS Webinar (2/27/2018): Neuro Interventional Radiology: Carotid Artery Stenting



okay we're gonna get started here hey everyone welcome to tonight's webinar my name is David and I'm a member with the RFS neurointerventional service line on behalf of the society interventional radiology resident fellow student section thank you for taking your time tonight to hear this webinar on carotid artery stenting before we begin our session I want to remind everyone that this webinar will be recorded and will be available on YouTube by searching I our education anyone is free to ask questions at any time simply by entering them into the chat box on the go to webinar control panel and we'll keep a track of them and answer them in the end also please check the RFS website regularly for upcoming events and follow us on twitter and facebook for other updates and postings of clinical material it's my pleasure to now introduce our speaker for tonight dr. Alan Brooke dr. Brooke is a fellow of the society interventional radiology and has been the director of interventional neuroradiology at Montefiore Medical Center since 1995 he's a professor of radiology and neurosurgery at the Albert Einstein College of Medicine he leads a multidisciplinary team who treats various cerebral vascular diseases including aneurysms and stroke he has a long-standing interest in teaching and as a director of the endovascular simulation center at the joint Montefiore Medical Center and Albert Einstein College of Medicine simulation center he's a past resident of the past president of the American Society of spine radiology and on the editorial board for neuroradiology journal thank you dr. Brooke for taking your time tonight to talk to us about carotid artery stenting so you can get started David thank you very much can everybody hear me I take that as a yes yes anyway I'm gonna try to talk for 4045 minutes and leave plenty of room and plenty of time for questions I'll give you little history on the carotid artery disease and where stenting falls into place when I first started doing this back in 1995-96 and they needed more carotid stents and I do presently given the literature so it's quite an interesting turn of events over the years but it's a great thing to know how to do when it's appropriate so why is cara de the carotid artery disease so important I think the basics are this is the main conduit from the heart to the brain and so this is the mechanism most strokes are caused from stroke is a third leading cause of death in this country after coronary artery disease and cancer strokes affect over 700,000 patients a year 165 thousand deaths annually and most importantly it's a leading cause of disability United States and it costs over fifty to seventy billion dollars a year to our country so if you have a stroke at age 40 and can't move your right arm or right leg or can't speak and affects you your family and of course you won't be able to work so what is stroke prevention the sole goal of carotid revascularization whether use endarterectomy or stenting is exactly the same thing to prevent a stroke the extracranial internal carotid artery accounts for about 30% of strokes about 35 to 40 percent come from the heart and the form of emboli in some are intrinsic disease within the brain and some are unknown to let the most recent statistics show about 200,000 carotid endarterectomy are performed annually and the carotid endarterectomy is one of the best tested surgeries ever based on NASA which is the North American trial that proved it's better than medical management so when we're talking about carotid disease we can't talk about carotid stenosis and we need to be on a very similar academic level how we're discussing it you can classify it mild moderate and severe of course but that doesn't give us numbers that correlate to how severe the stenosis is in a majority of us use an acid criteria which are based very differently from the European the EC ST and you can see that we measure it based on angiography the most narrowed segment of the stenosis compared to the most normal segment above the stenosis can you see through my arrows point to a normal segment above first most narrowed portion below and that ratio is considered mild zero to 49% moderate 50 to 79 percent or severe eighty to ninety nine percent so that's how you become mild moderate and severe stenosis based on a very standard criteria that's been driven by data in addition you can classify carotid disease on symptoms either it's asymptomatic that you saw on incidentally on imaging or heard of brewing the neck or it's symptomatic where you have a focal neurological symptom such as loss of vision which is called amaurosis fugax or at EIA or a stroke where you have weakness of an arm a leg can't speak or have some other neurological finding carotid breweries are very commonly hurt in the office but they're not always due to stenosis what you see the sensitivity is very low at 53% you could have a torturous carotid artery gave something pressing upon the carotid artery so it's a very easy cheap way of finding a stenosis but it's not very sensitive or specific the way we make the diagnosis of stenosis is based on the three non-invasive methods in a chronic duplex ultrasound CT angiography which is seek to you with I donated contrast or MRA and MRA can be done with or without catalunya and I'll show you a few different reasons why you would choose one way with Condors or the other duplex is something that some radiology departments do and some don't and it's really detecting a focal increase in blood flow and that's what measures of stenosis just like when you have a faucet that's narrowed it gets faster as it gets more narrowed and it's pretty sensitive and specific and of course the gold standard is angiography needs been comparing it in many trials and it's very very good the downside to carotid duplex it doesn't show you what's above or below the mid neck and I'll show you cases where that and become important CTA gives a very good anatomical configuration of the arteries and it can tell you all the way from the arch above the heart through the neck and into the brain so you get a complete arterial tree picture to know what's happening above and below the bifurcation as well and that becomes important CTA and ultrasound have some limitations if you have a very torturous carotid artery it's just it's very hard sometimes for Doppler to pick it up if you have severe calcification sometimes CTA can't see the parent artery lumen very well when you have a high bifurcation ultrasound is a difficult time finding it because you have the skull base in its way and when you have either congestive heart failure or a poor IV CTA can be misleading it is very very sensitive and very specific when done well even compared to conventional angiography now I'll show you a few cases where both are actually complementary not always one better than the other in this slide you can see how you can see all way down the Artic arch if there's a proximal common carotid lesion you can see where the arrow is in addition in the axial image the white arrow points to a small lumen all the way is centrally placed and angiography doesn't always show you the axial imaging as well in addition on CTA with reconstructions on many many different types of algorithms you can see the level of bifurcation whether it's at C 2 or C 5 you can see the length of the lesion you can see if there's alteration calcification and tortuosity so you can measure very nicely if you're thinking about placing a stent or doing angioplasty or just for the angiography portion of the study so it's very good for preoperative planning mr angiography has the benefit of not having any radiation you know I Internet contrast for those patients who have renal problems and you can do this with without contrast as well one of the drawbacks of MRI angiography is that it tends to overestimate the narrowing when you have good patient to sensitivity in specific is very very good it's always important to know that narrowing of a blood vessel is important but understanding the reason we're looking at the carotid arteries prevent a stroke if an artery is completely occluded like you seen the circle is here on your bottom right if one Cod is occluded the other carotid can help out through the anterior communicating artery and we see my arrow now or for the posterior communicating artery which this yellow arrow depicts here so sometimes if something's nearly included you don't always have to open it if the patient has good collateral circulation to the brain because the only reason you'd want to dilate it an artery or replace it is if the brain needs it open many times the collateral vessels are very very good in about 20% of time the anterior cerebral artery is hypoplastic on one side so you have to understand the entire way the blood is getting blood supply from the heart when you look at strokes you have to understand what symptomatic is on the right you see a large vessel user wedge-shaped image and this is diffusion-weighted imaging and they're right you have a small basal ganglia lacunar infarct that could be from a small vessel in part from the lenticular striae it's not necessarily embolic here you can see multiple tiny diffusion bright spots in a distal vasculature called the watershed that's where you sit between two territories a very distal ACA and MCA territories get less blood supply when there's a low blood pressure in addition it could be between the posterior cerebral artery in the middle cerebral artery where you get these watershed infarcts or from distal emboli if your symptoms are on the left and their strokes are on the right then you have to be careful that you didn't miss the cause of the stroke and not fix something that's asymptomatic as you'll see there's many reasons why you have to be of have a good clinical understanding as to why you're treating these patients Kayson head this is a patient presented with hemiparesis without a critical eye cos I see a stenosis you see there it's less than 50% but if it's if salado to the symptoms do you treat this you have to be very sure you understand the neurology behind these it's not just about fixing the pipes or a little better than being plumbers you can see here this patient hemiparesis because the basilar D was stenotic right here and there's a stroke in the pons and midbrain so you have to make sure you understand that there may be areas that mimic carotid stenosis one of them is a posterior circulation the other one could be a seizure or a brain tumor so that's why imaging the brain is so important and understanding the entire brain circulation clearly the gold standard on how all these tests in the criteria by NASA was made by Katharine angiography and you can see that with DSA the ulceration of the carotid is better seen in an MRA the downside to DSA digital subtraction imaging is that it uses eyes in any contrast and it has x-rays as well as it's an invasive procedure with some risk mainly embolic phenomenon or damaging an artery or allergy to any of the medications so when you do MRA you can also add to the ability to make it turn out much higher quality with patients hold still and you have good technology sometimes you need to sedate patients into if you add gadda lynnium you can see how much better the visualization of stenosis is just like using contrast material gadda lynnium has very minor risks but those with renal failure also you have to be very cautious as you all know so we once we've diagnosed carotid artery stenosis i want to go through some of the treatment options in the standard of care because you miss two noses we have to know how to treat it not everything is done surgically or and eventually medical treatment has gotten so significant it has become much better since the 1970s and 80s it's incredible and we're seeing so much less chronic disease where I work in the Bronx than ever before due to medical therapy and medical therapy really is there's three ways one is when you have carotid stenosis using statins antiplatelet agents of course and secondary prevention secondary prevention is very important smoking is one of the biggest vascular disease risk factors along with obesity in lack of physical activity there's many new studies out on a proper diets whether it's low carbohydrates or low fat diets the idea is it really makes a difference and we see it in everyday imaging and also when patients smoke the outcomes of all types of surgery are much more harsh so here's a lesion of the distal common carotid artery where you can see here then you see some calcification in the external artery external crowd already feel slowly so the severe stenosis at the bifurcation tree are not to treat that is the question so that what is the natural history if it's not symptomatic that's something that you need to know when you're advising your family or your patients well the statistics show about 90% of patients over a five-year period of time will not have a stroke when you have a symptomatic carotid disease of course makes a difference if it's 99% stenotic versus 50 to 79 percent at the same time this is something you need to discuss with your patients if they have comorbid diseases or their life expectancy is short then clearly you would not want to treat these patients this corresponds with the asymptomatic American Heart Association guidelines for carotid and Direct mean they say when it's greater than 70% stenosis you shouldn't treat everybody they also have to have a peri operative stroke and mi wrist that is less than 3% for the surgeon or for the center so they take into the count how good your Center is at treating these patients which is a lot of common sense but you have to know your own risk factors so what is a carotid endarterectomy if we're gonna talk about stenting which we spend a fair amount of time of the rest of the talk on that we have to understand what endarterectomy does when you try to understand how to triage these patients appropriately so it may make a small incision in the neck and then they open up the cross it and they take out the plaque and then they sew it up again so they actually isolate the carotid so there's no embolic phenomenon the risks of surgery are mainly stroke if you have an embolus a heart attack cranial nerve palsy and you can see the facial nerve the glossopharyngeal nerve Vegas and hypoglossal are very close to where the carotid artery is it's that's why they have they have deficits symptomatic stenosis is much different and this is from a very recent study from the current treatment options in cardiovascular medicine 2017 and shows if you have a symptomatic severe stenosis you haven't treat nine men yet to save one stroke and you can see the difference in less than 65 years old or a little greater than 75 years old so these are things that are very important in addition there's a lot of data saying that if you're it's within two weeks of the ti a or the stroke you only have to treat five patients to save one person from having a stroke over five years though if the stroke is already three months out you have to feed a hundred and twenty-five patients so the dog when now this the science is you need to treat as early as possible to prevent strokes when you do pooled analysis from multiple trials it with symptomatic carotid artery disease the mild stenosis does not show any benefit beneficial is greater than 70% stenosis shows significant I'm less strokes with time and all you only need to treat six patients to save one stroke in five years if they're over 70% and they're symptomatic you know this bull dolls been symptomatic only 50 to 69 percent now I need to treat 22 patients to save one stroke over five years these are very significant for informed consent with your patients so the guidelines say that if you have significant stenosis over 70% you know greater than five year life expectancy they recommend CEA carotid artery rather than medical management that's level one a evidence which is the highest American Heart Association level of evidence the things that makes it Khurana endarterectomy more risky oh it's on a severe car our disease a high risk for surgery a recent mi which is the biggest risk factor because many of the patients still undergo general anesthesia for carotid endarterectomy these are the risks that makes kurata anarkali also risky and you'll see these are the same things that make carotid stenting indicated when you have previous radiation it's harder surgery when you have bilateral severe disease it's hard to want to include a vessel for a period of 20 minutes to do the endarterectomy or when you have a contralateral carotid occlusion or laryngeal nerve palsy when they can't speak without one vocal cord being injured and so you wouldn't want to injure the other vocal cord these the reasons why CEA is of high risk and will turn into being the role of where carotid artery stenting comes into play and we're going to grab most of the time now talking about stenting so what are the indications one of them is someone who can't have an entire ectomy when you have damage to the contralateral vocal cord we just spoke about it's a lot of Prior and done directly did a lot of scarring in the area just like when you have neck radiation for cancer in that area when someone had a previous seeing your restenosis from intimal hyperplasia or when you have a poor Circle Willis and they have to do a bypass many of the master surgeons are neurosurgery to do carotid artery don't have a lot of experience in doing bypasses want to keep the brain having good blood flow once they're doing the endarterectomy very few contraindications as far as the medical man goes one is and I'll show you a few case like this when the anatomy is not favorable usually someone has allergic reaction contracts you could always pretreat them when someone has unfavorable access or they have abnormal plaques or clot in the vessel those cases you clearly want to avoid doing carotid stenting doing something through the vessel so what are the procedural steps before you do any procedure you have to have the proper informed consent and important to know how to medically manage these patients to maximize no embolic events during your procedure that's clearly putting someone on aspirin and plavix or clopidogrel for at least five days before the procedure patients can get tested if the platelets are appropriately being inhibited by these diseases nowadays and you need to know how to do those tests the thromboplastin fee so when you do crowded stenting there's a lot of different steps to these procedures and it all starts with access most patients you can use femoral axis cuz that's what we do most of if it's an epsilon old Zija views of brachial the radial approach and now the more and more vascular surgeons and neurosurgeons who can perform surgery do direct access to the carotid and do away with all the access problems coming from the brachial or the femoral approaches we won't go through that too often because most you don't do cut downs so what are the really intrinsic factors and make carotid stenting risky it's mostly due to what's in the artery because that's where your angioplasty balloon and stent go it's when you have a very soft plaque or a true Frank clot within the vessel for very severe stenosis when you have long segments of plaques usually more than a sonometer when you're hemorrhaging a plaque means it's not stable that's where statins really come into play that's why you like the book pages I had to play them for at least five days usually it makes it fibrous cap less unstable and when you'll see when things are around turns and curves it makes it harder to place your devices in addition if you have a patient who has the art dissection like this trying to pass catheters in and out of the true lumen can lead to more risky cases so those patients you can out not to do the case the most some of the most recent studies give very simple algorithms when you have stenosis either symptomatic or asymptomatic when it's symptomatic in severe stenosis or as high-risk features you can determine best medical therapy or revascularisation revascularisation go to stenting or indirectly depending on the patient's and the lesions intrinsic characteristics is something go either way or do both depending on what your skill sets are what your Center has so when you have someone not with a symptomatic carotid some of those may benefit from treatment as well those the ones that you see progression of stenosis over time with non-invasive image imaging or when they have MRI or ultrasound characteristics showing on with lesions that are at risk with you you see a plaque with hemorrhage in it or alterations when you this is when you have Micro emboli detect an ultrasound or when you're silent infarct on CT or MRI or you have low perfusion states with high resolution hemorrhage so these are reason why maybe asymptomatic patients would get treated but just very cautious because most of those do very very well with medical management a little history the first interim vascular angioplasty 4-quart carotid disease was done by klaus mathias in 1981 DeBakey was the first one who did it by surgery so what is stent assisted angioplasty or carotid stenting you essentially catheterize the common carotid artery and you place a wire across the stenosis into the internal carotid artery across the lesion you then either use a protection device you're not this picture just shows the stent distal to the stenosis and slowly open the stent usually it's just a pulling back of the catheter as a stent open these are all self-expanding stents we use in the carotid artery unlike the coronary stents which are balloon expanding stents you can see here there's residual stenosis and you may choose to angioplasty after the stent is already deployed so here's a typical cases this is courtesy of dr. sadi one of my colleagues a 73 year-old symptomatically current carotid stenosis after and prior carotid surgery you can see how it's irregular it's eccentric a little ulcerated but the artery is straight this is what it looks like an x-ray it's always important when you angiography you're reading your MRIs or your CAD scans with contrast to make sure you tell the surgeons what level of bifurcation is that here you can see that the c2 body's way above the bifurcation and the bifurcation starts at the bottom top of c4 goes to c3 you can see this patient already on a previous surgery by the clips here you can see that the stent is open across the residual stenosis the angioplasty balloon goes up and when the white arrow is it shows you the protection device which is I'll go through a more detail the next few slides and you can see the difference in pre and post that's a pretty standard procedure like we do it most importantly on the post you always look at the brain to make sure you didn't throw any emboli and you can see very nicely here and the pre image that the anti stream already wasn't even filled because the contralateral side was filling in and after the procedure you could see that the entire treat of the brain looks much better filled so how do you choose what to do at what times so you're going to see modifiable risk factors with both the lesion and the patient and we'll go through some of these with you now when you do the procedure the access the pre dilatation two different stent types distal protection closure devices anesthesia all make a difference depending on what the intrinsic lesion is in the arteries and in the patient's anatomy all these risk factors make all these procedures less safe especially if they're smokers or a bad COPD you have to look at it before you start a case to someone have a nice easy class one art what you see on your left or in class three or it's a very hard take off doing a femoral approach makes your procedure much more risky and many times you have to use dishes different types of catheters for access so knowing this ahead of time for the non amazing makes your consent process much more fair to the patient and their families so here's test question number one art vessels arising for the top of the arch is called a type one arch and then you see here where you the vessels go come off very low compared to the top of the arch this is a class three so trying to get a catheter to come up the descending aorta and cross over to the internal carotid artery be quite risky and possibly cause a dissection so these cases are much more risky and it may be better to send this to surgery or to take a different approach significant tortuosity even though the it's easy to access the origin the left common carotid artery the torch wants it down here makes a little more challenging so you have to be a little more experienced learning how to do these cases here's the case of bovine they're not all the same an easy both on in your left and they're very hard 90-degree angle both to the right left common carotid arteries coming off this type of bovine arch here's a very torturous internal crowd already past the severe stenosis and you can see how trying to lay a protection device down in a stent without straining the artery may be very difficult these cases are prone to have clot and to have dissections previously fitting healthy 44 year-old male develops sudden onset of right-sided weakness a nice interesting case while lifting weights in a gym you can see the MRI shows left-sided small infarcts and he developed transient aphasia over time as his blood pressure changed some of you may be guessing the diagnosis but you can see that the Angela's performed on your left that shows a complete occlusion of the internal carotid artery and after angioplasty you can see it's wide open after stenting it so this was a spontaneous carotid dissection and young patients they shouldn't have a thorough squad disease and it's actually a very different seize process and your thinking has been much different than if you get a standard athos go out in and I'll show you why on this picture you can see the flap on an angiogram but if you did a dissection a vessel the hematomas in the wall underneath the endothelium narrowing the blood vessel but putting stents in these is much safer usually an arthropod lesion because as the helium is still smooth and regular so these cases usually a treat with heparin or the anticoagulation antiplatelet unless they progress in the skull base or they have embolic phenomenon and have progressive stenosis but these are much safer to treat with stents this is another case where you see multiple areas of stenosis that looks like it's a flap when some maybe some clot in the wall could you do it indirectly here yes but the lesion goes way above the mandible and two we know that this case was another young patient with a dissection and just with heparin alone you can see the lumen is completely normal again so knowing the history of trauma in this case prevented us from doing something based on imaging alone clinical history and examination is still very important calcium on cat scan is very very easy to see on MRI it's very hard to see and even on angiography you can see that it's very hard to know how much calcification here were on CT it's elegant and trying to angioplasty this is very difficult and many times will lead to all kinds of changes do the carotid bulb innervation they get hypotensive and bradycardic and you have to be very cautious preoperative imaging you can see the CTA can be very elegant showing the different levels of calcification and ulceration ulceration sometimes has conformation in it it makes it very difficult sometimes to angioplasty this is a case of mine where you can see that you have false channels rique analyzing it through a clod and this is a picture of the Mayo Clinic proceedings that show these hemorrhagic and lipid lesions than when you angioplasty it easy throwing emboli to the brain this was a Bronx judge so we've covered well in the hospital he was 83 years old and he actually refused to have a CEA and so we did was we placed angioplasty balloon across it you could see the stent very nicely crossed with very little residual stenosis and we didn't need to do a post angioplasty balloon and the reason why was it almost acts like a cheese grater so you don't have to do you don't do it this is an earlier case we did without a protection device Beijing did very well with the orange arrow is you may see some cloud near there and using some antiplatelet drugs helps quite a bit this was on the left common carotid artery before I'm showing you this so as you film it you would see different filling rates you can see it's very narrowed here and the centric plaque and that external carotid artery doesn't always fill so when you plan a carotid stenting procedure one or where the bifurcation is you want to plan a straight segment to place your protection device whether it's a balloon or whether it's a filter most of us use filters nowadays and you want to know what size the vessel is comparing the common carotid artery and how long the stent should be and if you keep your bony landmarks on there with a roadmap you always know the bifurcation doesn't move compared to bone even if the patient moves or breeze you still the bony landmarks as your friend you can see that we use this protection device a filter placed above you each one has different sets of markers you need to be familiar with them and as I told you before that when you put these wires a lot of times the vessel straightens out it is very important to know where the bony landmarks are so you do your angioplasty and place the stent according to where the lesion is so challenges again around curves and when you can see a big waste in the stent you may have to angioplasty and you want to choose a balloon size and length appropriately in this case you can see that this filter device was placed at this level and after we place a stent which is beautifully opened here we don't see any filling through the protection device so at this point you need to make quick decisions on what's wrong the possibilities when the protection device is filled is one there's spasm of the artery and you can give either an antispasmodic like night to glycerin or verapamil to is there's clotting and you can't pacify it because of that and at that point is to try and take it out as soon as possible in a safe manner it's unlikely to be completely dissected but that is the other possibility at that point you want to get it out and see what the vessel looks like in this case we had to cotton it it's when we took the vest when we took the device I want to protect right we can see the vessel filling normally there was no dissection and no spasm in this vessel but sometimes you have to be aware when you do the iron jog review what you're going to find and how to deal with it in a timely manner you also check if the patient has the activated colleague time in the heparin ization level is correct during these procedures because these protection eyes can get filled with debris in addition you always look at the integrated vessels after your procedure to make sure that the brain is filling normally is no distal clot on the distal protection devices as many different kinds there's mostly people use filters so you give blood going through the brain some use balloons and some use actually flow reversal tanks where you put a balloon up in the common carotid artery gluing the external carotid and have reversal flow from suction so when you're using the angioplasty understand no emboli go to the brain there's too many top on a small segment this is another cartoon showing different types of protection devices and filters this is a cartoon from one of the manufacturers that shows stents of different sizes and how to place it safely I just want to show you this picture showing when you put your initial wire going through the plaque there's a lot of chance to throw distal embolization devices so you go very cautiously with small soft wires and if you see any redundancy you pull back and you go carefully and as you put the filter up you can see when you and your class to your stent the projection device can really pick up degrees like these limpets here that would have gone to the brain without the filter device there's many different types of stents there's not enough time to talk about all of them the idea is more and more sensor coming out with smaller closed cell designs even covered so you don't throw amble on when you're opening these up this is a case where sometimes when you have dissections of the aorta or that it's too you can actually go through the arm to do it this is a classic right-sided brain stroke from a high-grade snow so the right internal carotid artery the left was already included for a difficult time so stenting was thought to be safe as you can see there where the clot is in the aorta you know the ultrasound this was a radial poach we're using a 450 micro puncture you always give heparin because the arteries are small they tend to spasm along with at least 10 milligrams of rat mil and 100 micrograms of nitroglycerin to keep it from spasming we then upgrade to a five French guide catheter and you see it's you navigate over a wire into the common carotid artery into your angioplasty and stenting in standard fashion so the anatomy of the groin the anatomy of your arch can dictate you must use other approaches at times and you can see that what it looks like in angioplasty and stenting just like any other case going through the arm so the natural history of asymptomatic carotid stenosis in a review view that only approximately ten percent have strokes over five years some of these will have B major strokes you want to make sure that all your patients have maximal medical therapy but at times they won't be asymptomatic it more will have strokes so that's why these patients are watch with either six months of yearly ultrasounds of the neck or routine MRIs when emerets if they're symptomatic this is a case where it became occluded and when we went in to treat this you can see that there already was open but there was a clot in the brain one of the things that you have to know that you can have embolize from your procedures in this case would you to throw them back to me and pull the clot out so you have to be prepared for endovascular rescue if you're doing endovascular procedures the ideas of ever you're doing something you have to know the anatomy ahead of time and a way to prevent a complication from happening making sure you have your TPA or your kindness available or Rio pro if there's a distal Baalak event or around your device going through some of the literature I can't do a complete literature review a few because it's there's not enough time and one leave time for questions but crest and crest two are really the highlights of the carotid stent studies and it really measured carotid and direct me or carotid stenting plus intensive medical management and they compared it directly which was better Khurana and direct Mira crowded stenting versus medical management it's greater than 70% stenosis through even numbers of patients and clearly medical management has taken a huge leap forward and it involves watching the blood pressure keeping the cholesterol down as well as antiplatelet protocols this is the Samper study was into cranial stenting study that was showed that intracranial standing was not better than standard medical management but it really showed that antiplatelet and statins are way better than just using coumadin and it's sort of a 30-day rate of stroke or death was only 5% in the medical arm much lower than in previous trials which showed in cheek renal disease at least 10% over a short period of time given the time I want to go through a nice summary of what we've discussed and hopefully entice you to ask some questions with carotid endarterectomy instead he both complications could have stroke or death both can have a my and clearly with all the trials carotid artery stenting had more embolic events and carotid artery and more m eyes and there's known reasons for each one of those patients who are symptomatic both carotid endarterectomy instead he have a wide margin benefit over Natural History that's a known and the composite endpoint is the idea of knowing that either stroke death or MI is with measured in every single study that the randomized controlled study was showing superior of carotid and are to be over standing for strokes though credit artery clearly is more amara mm eyes myocardial infarcts so the question is you have to pick your poison but you should do it based on what initial factors medically that they as if they have congestive heart failure or coronary arteries stenting is probably safer if they have ugly-looking internal carotid artery stenosis and donor equity is clearly a safer procedure so when you look at high risk factors as both there's two types one is vessel and one is anatomic when someone has previous radiation or they have very high lesions you can think about extending is a very reasonable option so known as a contralateral laryngeal nerve palsy if someone has a high current just of heart failure risk think of doing stenting in your patients asymptomatic patient you better be very sure you can do your procedure safely because both carotid stenting and directly you have been a lot of patients to save one stroke there's multiple studies out there that really show that and our director he's clearly safer in the 30 day and 60 day period for emboli or strokes in and around the days of the procedure though after one year both procedures are shown to be safe and equal with as far as new strokes happening the anatomy whether it's callously calcifications or tortuosity it's very important and the biggest pearl I can give you is know the anatomy know the intrinsic nature and know the medical staff of your patient prior to puncturing or trying a procedure the goal of carotid stenting is to prevent a future stroke just like endarterectomy the idea is to perform every procedure with a 0% complication rate but the National rates are approximately 3% for symptomatic and 6% for symptomatic patients this is something that you should try more charting better than and the most important skill you can have is actually patient selection so your high-risk carotid stenting patients should virtually never get a stent common sense and your high risk for cardiac we should think about better medical therapy or go for stenting so if I could leave you with one thing as we say for your patients and really check your ego at the door a colleague of mine came over this and your goal is not to do a carotid stent on a hard percent of the patients who need carotid revascularization because you're you are so good the idea is I you want your patients to have revascularisation with the least chance of having a stroke your goal is to a carotid stents on appropriate patients who need carotid revascularisation and refer ones who really are better suited for gruntin and artery to your colleagues and overall you'll have a much better complication rate than that at which procedure they get so your consent process has to be fair to the patients or families and to your colleagues at your Medical Center which is safe and for your patient populations so I think we have time now for questions some of my slides came from dr. Don heck in some of dr. sadi where I thought appropriate and are there any questions um first of all that was a great talk dr. Brooke thank you very much if anyone has any questions they could just type it into the chat box and we'll bring it up to address it – dr. Brooke in the meantime something that I was thinking about during the talk is about stent restenosis do you ever find you know there's talk in terms of coronary stents like the rates of restenosis that's a great question we see we stenosis when there's a lot of calcified plaque some patients develop restenosis sooner than others but it can happen both in the acute setting over a month or two as well as more chronic usually restenosis is thought of intimal hyperplasia where it's more of a fibrotic nature to it and it's very smooth those are fairly easy to re angioplasty that should only be done if it's the same criteria if it's symptomatic or if it's ears to nose is greater than 70 percent just like before you started because it's 50% narrowed and smooth doesn't mean it needs to be treated in addition some of the reason to know is this actually is new plaque that's formed in similar areas because all you was pushed previous plot on the way to make a larger vessel so you're not always certain if it's restenosis due to fibrosis intimal hyperplasia which is safer to treat or it's actually plaque in lipid and hemorrhage that's really you later uh-huh okay thank you if anyone has any other questions feel free again to type it into the chat box but just another question that I was thinking about is I understand from the talk that most of the times you're dealing with the internal carotid artery you guys often find yourselves those external carotid artery so that's a great question there's very few reports of external carotid artery stenting when you stand across it many times you can include it the usual it stays open the only time to deal with the external is if there's a stump there and it's throwing emboli to your internal to if the internal auditory internal carotid artery is occluded and patient is getting collateral flow to the internal crowd already above from the external and it's static and so you can and your plastic that rarely do you stent the external carotid artery when we have patients with cancer and they have carotid blogs we use coverage stents and stent grafts to treat those and whenever we place it in the internal carotid artery of course you exclude the external carotid artery so cancer patients have a whole nother risk factor and profile of what type of devices we use but it's kind of out of the arena for this talk right okay and just the last question what do you what do you think are the next steps in terms of future studies related to carotid artery disease that's also a very nice question we have a ton of literature going out now on direct carotid punctures or cut downs so you cut out all the tortuosity and surgeons are doing a lot of those and then they place the stent under fluoroscopic like we do nowadays in addition there's all kinds of flowy versal techniques as many different ones they're out there now that actually put a balloon up proximal to the carotid blue in the external reverse the flow so when you do an angioplasty or stent emboli would come backwards similar to we do now an acute stroke work many of us do acute thrombectomy x' and we place a balloon in the common carotid artery or the internal carotid artery usually internal so when we're using a thrombectomy the brain we're actually doing flow reversal it's no emboli go to the brain and that's one of the big new procedures that are being developed at fortune those devices are quite large and closing the arteries with sutures can be somewhat challenging if you're doing it locally in a common carotid artery so there's a whole new plethora of doctors going direct prodded access or with complete flow reversal to avoid the distal end line wow that sounds really cool um all right so I don't think we have any more questions so thank you for that and I guess we'll wrap it up over here great thank you very much for putting this together and I look forward to having many more of you doing this procedure and coming to the SAR and you'll meet great thank you so much for your time dr. Brooke have a good night everyone


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