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Carotid Artery Stenting Periprocedural Care

  • Author: Faisal Aziz, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
 
Updated: Apr 08, 2016
 

Equipment

Listed below are the standard equipment and materials needed for carotid artery stenting (CAS). All interventionalists who are performing percutaneous carotid interventions should choose their equipment in accordance with their personal preferences and with the local availability of specific materials and devices.

Access kit

Access can be obtained using a micropuncture kit (Cook, Inc). This kit consists of a 21-gauge needle for obtaining access to the vessel, Torq-Flex® wire, and a coaxial catheter.

Guide wires

The following two wires can be used:

  • 0.035-in. hydrophilic guide wire (Terumo) to access the aortic arch
  • 0.014-in. hydrophilic guide wire (Spartacore) to cross the lesion

Introducer sheaths

A 6-French access sheath can be used initially, then a 6-French long guiding sheath system.

Catheters

To gain access to the aortic arch and advance the guide wire through the carotid lesion, complex catheter manipulations may be required, especially if the patient has a tortuous anatomy. Catheters with varying degrees of angulation assist in minimally traumatic catheter passage. Available catheters include the following:

  • JB-2 catheter (Cook, Inc)
  • SIM 1 catheter (Cook, Inc)
  • SIM 2 catheter (Cook, Inc)
  • H1 catheter (Cook, Inc)
  • VTK catheter (Terumo)
  • Glide vertebral catheter
  • Simmons catheter
  • Mani catheter

Balloon systems

There are two main types of balloon systems: coaxial and monorail. For carotid interventions, monorail balloons can be used, with predilation of the lesion with a 2- or 3-mm balloon.

The balloon length is chosen according to the length of the stenotic lesion. To reduce the risk of atheroembolization, poststent dilation is generally avoided. If such dilation is required, a 5- or 6-mm balloon is used, depending on the diameter of the stent and the diameter of the stenotic lesion.

Stents (balloon-expandable and self-expanding)

There are two basic types of stents: balloon-expandable and self-expanding.

Balloon-expandable stents are mounted on a balloon catheter and passively enlarged to the desired diameter at the implantation site by dilating the balloon. They are better suited for proximal carotid artery and innominate artery lesions and offer greater precision during CAS. Their collapsed diameter is slightly larger than that of self-expanding stents; therefore, it is often difficult to cross a lesion with them unless the stenosis is predilated. The Express® stent (Boston Scientific) is the available balloon-mounted stent for carotid artery lesions.

Self-expanding carotid stents are used as a minimally invasive alternative to carotid endarterectomy (CEA). They open actively after being released from the delivery system. Their self-expanding character depends either on the braiding structure or on the type of alloy (usually nitinol or stainless steel). Commercially available self-expanding stents include the following:

  • Carotid WALLSTENT ® (Boston Scientific)
  • Nexstent ® (Boston Scientific)
  • Precise ® (Cordis)
  • Protege ® (ev3)
  • Xact ® (Abbott)

Cerebral protection devices

The purpose of cerebral protection devices (CPDs) is to capture atherosclerotic emboli during catheter manipulation, angioplasty, and stenting. The risk of atheroembolization is greatest during balloon angioplasty of the stenosis and when the lesion is crossed by a wire. Different types of CPDs are commercially available, as follows:

  • GuardWire ® temporary occlusion and aspiration system (Medtronic) - This is available in two balloon sizes, 2.5-5 mm and 3-6 mm, on a 0.014-in. wire system
  • GORE Neuro Protection System (W. L. Gore & Associates; previously called Parodi Anti-Embolic System) - This system, based on the hemodynamic principle of reversal of internal carotid artery blood flow with common carotid artery occlusion, comes with a set of two balloons, one placed in the external carotid artery and the other in the common carotid artery; when both balloons are inflated, backbleeding generally occurs from the internal carotid artery
  • Filterwire EZ ® embolic protection system (Boston Scientific) - The basic mechanism is filter-based; it is based on a 0.014-in. wire system
  • Angioguard RX ® emboli capture guide wire system (Cordis)
  • RX Accunet ® embolic protection system (Abbott)
  • Emboshield NAV6 ® embolic protection system (Abbott)
  • Spider FX ® embolic protection device (ev3)
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Patient Preparation

Anesthesia

Conscious sedation and local anesthesia are preferred so as to permit continuous monitoring of the patient’s neurologic status. During balloon inflation, bradycardia and hypotension may occur; therefore, continuous cardiac monitoring and intra-arterial blood pressure monitoring are performed in all patients who undergo CAS.

Positioning

Carotid stenting procedures are performed in a hybrid, fixed C-arm operating room where multiplanar views are easily obtained. The patient is supine, with the head turned toward the opposite side. The operating surgeon usually stands on the patient's right side. Extra table length is added at the foot of the table to ensure that all wire lengths can be handled easily in a sterile field.

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Contributor Information and Disclosures
Author

Faisal Aziz, MD Assistant Professor of Surgery, Divsion of Vascular and Endovascular Surgery, Department of Surgery, Pennsylvania State University College of Medicine

Faisal Aziz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Anthony J Comerota, MD, FACS, FACC, FRACS Director of Jobst Vascular Institute, Program Director of General Vascular Surgery Residency, Toledo Hospital; Director of Jobst (ProMedica) Vascular Laboratories; Adjunct Professor of Surgery, Department of Surgery, University of Michigan Medical School

Anthony J Comerota, MD, FACS, FACC, FRACS is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Society for Vascular Surgery, Society of University Surgeons, American Stroke Association, American Venous Forum, Eastern Vascular Society, Society for Clinical Vascular Surgery

Disclosure: Received honoraria from BMS for speaking and teaching; Received consulting fee from BMS for consulting; Received grant/research funds from BMS for research studies; Received honoraria from Covidien for speaking and teaching; Received consulting fee from Covidien for consulting; Received honoraria from Otsuka for speaking and teaching; Received honoraria from Sanofi/Aventis for speaking and teaching; Received consulting fee from Sanofi/Aventis for consulting; Received grant/research funds from Sa.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Karlheinz Peter, MD, PhD Professor of Medicine, Monash University; Head of Centre of Thrombosis and Myocardial Infarction, Head of Division of Atherothrombosis and Vascular Biology, Associate Director, Baker Heart Research Institute; Interventional Cardiologist, The Alfred Hospital, Australia

Karlheinz Peter, MD, PhD is a member of the following medical societies: American Heart Association, German Cardiac Society, Cardiac Society of Australia and New Zealand

Disclosure: Nothing to disclose.

References
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Key steps in carotid stenting. Image courtesy of Kurt Mansor, Jobst Vascular Institute.
Images show vessel before and after carotid artery stenting. Image courtesy of Cheong Lee, MD.
 
 
 
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