456 Practical Handbook of Advanced Interventional Cardiology To solve the problem of a weak platform created by a fl oppy wire (mechanism 1), the wire has to be advanced further so the stiff segment is in the proper area. If the wire is not strong enough, it has to be exchanged to a stiffer one. 65 To solve the problem of acute angle at the origin of the artery (mechanism 2), a stiff wire will straighten out the angle and help to advance the wire. To solve the problem created by mechanism 3 due to excessive friction between the wire and the internal surface of the catheter, the cath- eter should be advanced and the guidewire withdrawn Figure 22-14: Diffi culty in advancing the catheter over the guidewire. (A) The catheter forms a loop in the aorta. (B) The tip of the catheter fl ips back into the aorta. (Adapted from Gerlock AJ, Mirfakhraee M. Diffi culty in catheterization of the internal and external carotid arteries. In: Gerlock AJ, Mirfa- khraee M, eds. Essentials of Diagnostic and Interventional Angiographic Techniques. WB Saunders, 1985. With permis- sion from the publisher.) Table 22-6 Mechanisms of failure in advancing the catheter 1. The wire is not strong enough to support the catheter. 2. The angle of the origin of the carotid artery is too acute. 3. Too much friction exists between the guidewire and the internal surface of the catheter. 4. The curve of the distal end of the catheter prevents further advancement. Carotid Artery Interventions 457 simultaneously (Figure 22-15). This maneuver reduces signifi cantly the friction between the wire and the internal surface of the catheter. Another way is to change the size of the wire to a smaller one, although this wire would not provide the same support as the previous wire; however, it would help to advance the catheter if the problem is related primarily to friction rather than support. 65 To solve the problem of mechanism 4 (a sharp angle at the end of the catheter), while the wire is fi xed, the catheter is advanced over it while rotating the catheter gently. The goal is to straighten the distal segment of the catheter by the wall of the artery so the catheter can adopt itself more to the angle and be advanced further (Figure 22-16). In diffi cult situations, two or three of the above-mentioned maneuvers may be required before the tip of the catheter can be ad- vanced to the desired level. ***Carotid access in presence of occluded ECA, CCA lesion below bifurcation, or ostial CCA lesion: Placing the 7F 90-cm access sheath into the CCA may present Figure 22-15: Diagram showing how to reduce the friction between the wire and the internal surface of the catheter. (A) The catheter tip is at the orifi ce of the left CCA and the tip of the wire is in the left ICA. (B) The catheter is advanced while the wire is withdrawn. (Adapted from Gerlock AJ, Mirfakhraee M. Diffi culty in catheterization of the internal and external carotid arteries. In: Gerlock AJ, Mirfakhraee M, eds. Essentials of Diagnostic and Interventional Angiographic Techniques. WB Saunders, 1985. With permission from the publisher.) 458 Practical Handbook of Advanced Interventional Cardiology special challenges when the ECA is occluded, a critical lesion is situated below the bifurcation, or there is a critical ostial common carotid lesion. If possible, avoid crossing the lesion with a stiff 0.038" wire since this is more likely to disrupt the necrotic plaque material and cause distal embolization. When possible, advance the 5F diagnostic guide over the 0.038" glidewire to be placed more distally. In this situation, the glidewire and 5F guide are fi rst advanced through the lesion. This maneuver should be done only in patients considered at high risk from carotid surgery if the risk-benefi t ratio still favors stenting. In the presence of a carotid ostial lesion, the origin of the CCA should be fi rst dilated to allow sheath access. The bifurcation should be stented fi rst, and the ostium stented with a Palmaz stent on the “way out”. ***Choice of balloon expandable or self-expandable stents: The use of balloon expandable stents was aban- doned with 3 exceptions listed in Table 22-7. Forcing the current high-profi le delivery systems may break off plaque and cause distal embolization. In this situation, a short bal- Figure 22-16: Straightening the tip of the catheter by the wall of the artery. (A) The tip of the catheter is at the orifi ce of the left CCA. (B) While the wire is fi xed, the catheter is advanced over it using rotating forward movement. (C) The catheter has advanced over the wire into the vessel. (Adapted from Gerlock AJ, Mirfakhraee M. Diffi culty in catheterization of the internal and external carotid arteries. In: Gerlock AJ, Mirfakhraee M, eds. Essentials of Diagnostic and Interventional Angiograph- ic Techniques. WB Saunders, 1985. With permission from the publisher.) Carotid Artery Interventions 459 loon expandable stent may be placed to hold the lesion open before passing a defi nitive self-expanding stent. **Postdilation: It is safer to underdilate than overdilate the oversized self-expanding stents. Overdilatation squeezes the atherosclerotic material through the stent mesh, caus- ing emboli. A 10–15% remaining stenosis does not cause clinical problems. Importantly, it is not necessary to dilate the stent to obliterate segments of contrast-fi lled ulcer- ations external to the stent. This angiographic appearance is of no prognostic signifi cance and follow-up angiography has documented complete fi brotic healing of these lesions over time. Importantly, it is not necessary to overexpand the stent to produce a 0% residual diameter narrowing. Covering the external carotid artery with a stent does not cause problems. Our follow-up arteriograms showed the external carotid artery to be patent with rare exceptions. If the external carotid artery becomes signifi cantly stenosed with <TIMI-3 fl ow or occluded after postdilation of the stent, this vessel can be approached through the stent mesh, and reopened using coronary balloon techniques. A 0.014" wire is used to enter the external carotid artery, a 2-mm balloon to predilate, and a 4-mm balloon for fi nal dilation. However there is almost never a clinical indication to do this. COMPLICATIONS OF CAROTID INTERVENTIONS Although major complications can be encountered dur- ing the learning curve of carotid angioplasty and stenting, 66 they are minimized by the use of meticulous techniques. Thrombotic and embolic complications: A recent survey on carotid artery angioplasty and stenting 67 revealed a 30-day minor stroke rate of 2.72% and a major stroke rate of 1.49%. Advantages of the endovascular approach over CEA include the ability to immediately diagnose and treat these complications, and the patient can be awake, allowing close Table 22-7 Indications for use of balloon expandable stents 1. When the ostium of the common carotid artery is treated and the proximal end of the stent has to be placed with precision. 2. When the most distal segment of the internal carotid artery is treated (present delivery systems for a self- expanding stent cause dissections in the petrous portion of the internal carotid artery). 3. When the self-expanding stent delivery system will not pass through a calcifi ed, recoiling lesion. 460 Practical Handbook of Advanced Interventional Cardiology neurologic monitoring. For acute thrombosis, local intra-ar- terial thrombolysis can be carried out using mechanical as well as chemical disruption of the clot. 68 Extreme care must be exercised to avoid vessel perforation. Only very fl exible microcatheters and soft wires may be used in the intracerebral circulation. To prevent thrombotic complications, investigators have advocated the use of glycoprotein 2b3a platelet inhibition. 69 However, this encounters the risk of cerebral bleeding and therefore it should not be used routinely. Today, embolic protection devices are widely used although no randomized trials with versus without protection have been performed. 70 Atherosclerotic debris can be found in the fi lter in the majority of cases. Therefore, most investigators consider it to be un- ethical to conduct such a trial. Carotid artery spasm: Guidewire-induced phenomena are minimized by the use of 0.014–0.018" wires. Carotid artery spasm can be successfully treated with papaverine 21 or nitro- glycerin. Often they disappear spontaneously. Transient bradyarrythmias and hypotension: Medi- ated by stretch of the carotid baroreceptors. This can usually be avoided by atropine given at least 2 to 3 minutes before balloon infl ation. Asystole is very rare, but if it occurs, it is transient and resolves with balloon defl ation. A routine pacemaker is not necessary. Post-stenting hypotension: Mediated by stretch of the carotid baroreceptors. Treat aggressively if the patient has severe distal or contralateral disease. Puncture site complica- tions should be ruled out. 58 External carotid artery occlusion: Acute occlusion of the ECA is well tolerated. In the absence of collateral circula- tion, patients may experience jaw muscle angina which is usually transient. Stent restenosis: The restenosis rate for carotid stent- ing is less than 10%. It is treated with balloon dilatation. 71 A new stenosis may occur at the distal end of a stiff stent. This may require an additional stent. Carotid perforation: This can be seen after excessive balloon sizing prior to or after stent placement. If encoun- tered, try to seal it with a prolonged balloon infl ation. Covered stents can be used if there is no compromise of major side branches. Carotid dissection: This is seen mainly in areas of ves- sel tortuosity or calcifi cation. Stented segments should not be overdilated in comparison to the reference vessel. Further stenting may be necessary to avoid fl ow disruption in the area of dissection. Cerebral hemorrhage: Associated with a combination of excessive anticoagulation, uncontrolled hypertension, intracranial vessel manipulation, and stenting after a recent Carotid Artery Interventions 461 stroke (<3 weeks). Terminate the procedure, reverse the anticoagulation, and control the hypertension. An emergency brain CT scan should be performed. Operators should be fa- miliar with the angiographic features of an intracranial mass effect. Sudden loss of consciousness preceded by a severe headache in the absence of intracranial vessel occlusion should alert the operator to this devastating event. Fortu- nately, with careful patient selection and compulsive attention to the above technical and anticoagulation issues, cerebral hem orrhage sh ould b e a ver y r are oc currence. Jaw claudication: After carotid stenting, some patients complain of pain when masticating, especially if the ECA is jailed. Jaw claudication should slowly disappear in 1 to 2 weeks. Problems and complications with embolic protec- tion devices: Embolic protection devices may also cause problems. All devices placed distally in the internal carotid ar- tery may cause spasm or dissection. Rarely additional balloon infl ations and/or stent implantations have been necessary to solve the problem. It may be diffi cult to retrieve these devices through the implanted stent. It may happen that the fi lter is not fully apposed to the vessel wall. In contrast, the major disad- vantage of the occlusion devices is intolerance in patients with occlusion or high-grade stenosis of the contralateral internal carotid artery or patients with poorly developed intracranial collaterals. A specifi c disadvantage of the MO.MA and the ArteriA device is the need for a large sheath, which may cause vascular access problems. FUTURE DIRECTIONS Future developments in the fi eld of carotid percutaneous intervention will include new stents with higher fl exibility which can be introduced through smaller sheaths (5F). We will have improved embolic protection devices with better wall apposi- tion and without need for a retrieval catheter. All these new developments will help carotid stenting to become the new gold standard for treatment of carotid arteriosclerotic disease within the next few years. REFERENCES 1. Wolf PA, Kannel WB, McGee PC. Epidemiology of strokes in North America. In: Barnet HJM, Stein BM, Mohr JP, Yatsu FM, eds. 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AZ), and *Basic; * *Advanced; ***Rare, exotic, or investigational From: Nguyen T, Hu D, Saito S, Grines C, Palacios I (eds), Practical Handbook of Advanced Interventional Cardiology, 2nd edn © 2003 Futura, an imprint of Blackwell Publishing 467 4 68 Practical Handbook of Advanced Interventional Cardiology the Teramed graft (Cordis Endovascular, Warren, NJ) have been introduced Most of these designs have... **Severe subvalvular disease undetected by echocardiography *Basic; * *Advanced; ***Rare, exotic, or investigational From: Nguyen T, Hu D, Saito S, Grines C, Palacios I (eds), Practical Handbook of Advanced Interventional Cardiology, 2nd edn © 2003 Futura, an imprint of Blackwell Publishing 485 486 Practical Handbook of Advanced Interventional Cardiology **Balloon sizing in patients with pliable, noncalcified... open surgery.22 In addition, patients who have had 482 Practical Handbook of Advanced Interventional Cardiology Figure 2 3-1 2: Completed deployment of the Endologix graft surgical AAA repair report substantial functional impairment; a third of the patients in one trial stated they had not fully recovered at a mean follow-up of 34 months, and nearly 20% of patients said they would not undergo AAA repair... above, patient selection that is based on careful evaluation of vascular anatomy is extremely important in the overall success of the endovascular AAA procedure Endoleaks are treated by a variety of means, including conversion to surgical repair, or insertion of a new stent or 4 78 Practical Handbook of Advanced Interventional Cardiology Figure 2 3 -8 : (Continued from Fig 23.7) The prosthesis is held in position... 22 : 257–64 18 Arko FR, Lee WA, Hill BB, Cipriano P, Fogarty TJ, Zarins CK Increased flexibility of AneuRx stent-graft reduces the need for secondary intervention following endovascular aneurysm repair J Endovasc Ther 2001; 8: 583 –91 19 Biancari F, Ylonen K, Anttila V et al Durability of open repair of infrarenal abdominal aortic aneurysm: a 15-year follow-up study J Vasc Surg 2002; 35: 87 –93 20 Treiman...466 Practical Handbook of Advanced Interventional Cardiology 69 Coller BS GPIIb/IIIa antagonists: Pathophysiologic and therapeutic insights from studies of c7E3 Fab Thromb Haemost 1997; 78: 730–5 70 Kastrup A, Groschel K, Krapf H et al Early outcome of carotid angioplasty and stenting with and without cerebral protection devices: a systematic review of the literature Stroke 2003; 34 (3): 81 3–19 71 Chakhtoura... Tuan, Pham Manh Hung, Moo Hyun Kim, Kean Wah Lau General overview Location of transseptal access **Variances of the mid-line **Appropriateness of the Inoue method Septal puncture **Exact positioning of the tip of the catheter/needle **Exact positioning of the tip of the needle/catheter in giant left atrium **Repositioning the tip of the needle/catheter after failed first try **Needle tip reshaping **How... until its tip extends beyond the catheter Then withdraw the needle Table 2 4-1 Instruments for septal puncture 1 A Brockenbrough needle 2 A 7F or 8F dilator catheter 3 An outer sheath catheter 488 Practical Handbook of Advanced Interventional Cardiology Figure 2 4-1 : Catheter/needle fitting exercise (A) First, fully insert the transseptal needle until its tip extends beyond the dilator tip (B) The needle... left atrium, and thus point L should be on the right atrial border because there is no septum laterally beyond 490 Practical Handbook of Advanced Interventional Cardiology Figure 2 4-2 : The “mid-line.” The upper end of the tricuspid valve at systole (T) is determined on a stop-frame frontal right atrial angiographic image (left panel) and translated to a stopframe left atrial image (right panel) On... is pulled to release the contralateral limb (Figs 2 3-7 and 2 3 -8 ), and the last stent is released to complete the deployment of the main body (Figure 2 3-9 ) The pusher rod is further advanced until it encapsulates the nose cone The nose cone is withdrawn through the body of the graft down to Endovascular Abdominal Aortic Aneurysm Exclusion 473 Figure 2 3-3 : The stiff delivery wire is placed, and the contralateral . eds. Essentials of Diagnostic and Interventional Angiographic Techniques. WB Saunders, 1 985 . With permission from the publisher.) 4 58 Practical Handbook of Advanced Interventional Cardiology special. (2): 1 68 9. 68. Wechsler LR, Jungreis CA. Intra-arterial thrombolysis for carotid circulation ischemia. Crit Care Clin 1999; 15: 701– 18. 466 Practical Handbook of Advanced Interventional Cardiology 69 calcifi ed, recoiling lesion. 460 Practical Handbook of Advanced Interventional Cardiology neurologic monitoring. For acute thrombosis, local intra-ar- terial thrombolysis can be carried out using