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This didactic procedure concerns a 70 years old man presenting with asymptomatic severe calcified and ulcerated left internal carotid on echography. Angiography revealed a severe ulcerated stenosis of the left internal carotid artery.

Educational objectives

  • Plan a step-by-step carotid artery stenting procedure.
  • 48 hours of dual antiplatelet therapy before the procedure;
  • Interruption of anti-hypertensive therapy the day before
  • How to manage access through tortuous anatomy?
  • Materials choice: guidewires, protection filter, guiding catheter, balloons and carotid stent.
  • How to prepare, advance the embolic protection system: FilterWire EZ™ through the lesion and release the filter upstream the lesion?
  • Tips and tricks for a good positioning and implantation of the Mesh carotid stent: CGUARD™EPS
  • How to safely retrieve the embolic protection system: FilterWire EZ™?
  • What are adjunctive per procedural pharmacotherapies

 

Step-by-step procedure: Left internal carotid artery stenting

1) Access sites:

  • Femoral access: 8 French access using micro puncture system.
  • Heparin administration.

2) Left common carotid artery catheterization:

  • Continuous flushing of the guiding catheter while introducing guidewire, embolic protection device, balloons or stent.
  • Advance softly an 8 Fr Hockey Stick guiding catheter to the aortic arch over a 0.035’’ GUIDEWIRE
  • Gentle Catheterization of the ostium of the left common carotid artery.
  • Advance the 0.035” Guidewire towards the common carotid artery.
  • Advance the guiding catheter to the distal part of the common carotid artery with the tip oriented towards the internal carotid ostium.

3) Preparation and deployment of embolic protection system: FilterWire EZ™:

  • Preparation of the filter with a special attention to avoid air bubbles.
  • Preform the wire tip shape according to the lesion morphology.
  • Careful and gentle crossing of the lesion avoiding plaque destabilization.
  • Release the filter in a vertical segment of the internal carotid distally to the lesion: be sure to have enough space for stent distal landing zone.
  • Verify the good position and the opening of the filter under fluoroscopy.

4) Pre-dilatation

Atropine administration

  • Good balloon preparation: avoid air bubbles to avoid cerebral air embolism in case of balloon rupture.
  • Pre dilatation of the lesion using a 4*20mm Ultra-Soft™ balloon , inflated to 4 ATM
  • Checking pre dilatation result

5) Stenting

  • Select the precise spot of stent deployment
  • Deployment of the CGUARD™EPS 9x30 mm Stent

6) Post-dilatation

  • Post dilatation of the lesion using a 5,5 *20mm Ultra-Soft™ balloon. Inflated to 15 ATM
  • Checking post dilatation result

7) CT scan after procedure showed : Excellent deployment of the stent

  • Check the filter content and the quality of the flow.
  • Remove the filter.
  • Verify if there is any dissection or spasm.

8) Final angiographic control: Cervical and Intra-cranial ( 2 views frontal & lateral)

9) Vascular femoral closure with an 8 Fr Angio-Seal™

10) Medical adjunctive treatments

  • Pre-procedural: Heparin.
  • During procedure : Atropine and ephedrine
  • Post procedural : double therapy: Aspirin 75mg o.d. + Clopidogrel 75mg o.d for one month
  • After one month : Stop Clopidogrel and continue Aspirin 75mg

 

Bibliography

 
 
 
 
 
 
 
 
 
Shooting date : 2022-05-04
Last update : 2023-07-11
Max Amor
Essey-lès-Nancy, France
Julien Lemoine
Essey-Lès-Nancy, France

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  • Mohamed amine R.

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