Table Of ContentH C P C I
ANDBOOK OF OMPLEX ERCUTANEOUS AROTID NTERVENTION
C C
ONTEMPORARY ARDIOLOGY
CHRISTOPHER P. CANNON, MD
SERIES EDITOR
ANNEMARIE M. ARMANI, MD
EXECUTIVE EDITOR
Cardiovascular Magnetic Resonance Imaging, Principles of Molecular Cardiology,editedby
edited byRaymond Y. Kwong, MD,2007 Marschall S. Runge, MD, and Cam Patterson,
Essential Echocardiography: A Practical Handbook MD, 2005
With DVD, edited by Scott D. Solomon, MD, Heart Disease Diagnosis and Therapy: A Practical
2007 Approach, Second Edition, byM. Gabriel Khan,
Management of Acute Pulmonary Embolism, MD,FRCP(LONDON),FRCP(C),FACP,FACC, 2005
edited by Stavros Konstantinides, MD, 2007 Cardiovascular Genomics: Gene Mining for
Stem Cells and Myocardial Regeneration,edited Pharmacogenomics and Gene Therapy,
byMarc S. Penn, MD,PhD, 2007 editedbyMohan K. Raizada, PhD, Julian F.
Handbook of Complex Percutaneous Carotid R. Paton, PhD, Michael J. Katovich, PhD, and
Intervention,edited by Jacqueline Saw, MD, Sergey Kasparov, MD,PhD, 2005
Jose Exaire, MD, David S. Lee, MD, Sanjay Surgical Management of Congestive Heart Failure,
Yadav,MD, 2007 editedbyJames C. Fang, MD
Preventive Cardiology:Insights Into the Prevention and Gregory S. Couper, MD, 2005
and Treatment of Cardiovascular Disease, Cardiopulmonary Resuscitation,editedbyJoseph P.
Second Edition,edited by JoAnne Micale Ornato,MD,FACP,FACC,FACEPand Mary Ann
Foody,MD, 2006 Peberdy,MD,FACC, 2005
The Art and Science of Cardiac Physical CT of the Heart: Principles and Applications, edited
Examination:With Heart Sounds and Pulse byU. Joseph Schoepf, MD, 2005
Wave Forms on CD,byNarasimhan Coronary Disease in Women:Evidence-Based Diag-
Ranganathan,MD, Vahe Sivaciyan, MD, nosis and Treatment,edited by Leslee J. Shaw,
and Franklin B. Saksena, MD, 2006 PhDand Rita F. Redberg, MD,FACC, 2004
Cardiovascular Biomarkers: Pathophysiology Cardiac Transplantation: The Columbia University
and Disease Management,editedbyDavid A. Medical Center/New York-Presbyterian
Hospital Manual, editedbyNiloo M. Edwards,
Morrow,MD, 2006
Cardiovascular Disease in the Elderly,editedby MD, Jonathan M. Chen, MD, and Pamela A.
Mazzeo, 2004
Gary Gerstenblith, MD, 2005
Heart Disease and Erectile Dysfunction,editedby
Platelet Function: Assessment, Diagnosis, and
Treatment,editedbyMartin Quinn, MBBCh Robert A. Kloner, MD,PhD, 2004
Complementary and Alternative Cardiovascular
BAO,PhD, and Desmond Fitzgerald, MD,FRCPI,
FESC,APP, 2005 Medicine,editedbyRichard A. Stein, MD
and Mehmet C. Oz, MD, 2004
Diabetes and Cardiovascular Disease, Second
Nuclear Cardiology, The Basics: How to Set Up
Edition,editedbyMichael T. Johnstone, MD,CM, and Maintain a Laboratory, byFrans J. Th.
FRCP(C), and Aristidis Veves, MD,DSc, 2005 Wackers,MD,PhD, Wendy Bruni, BS,CNMT,
Angiogenesis and Direct Myocardial
and Barry L. Zaret, MD, 2004
Revascularization,editedbyRoger J.
Minimally Invasive Cardiac Surgery, Second
Laham,MD, and Donald S. Baim, MD, 2005 Edition,edited by Daniel J. Goldstein,MD,
Interventional Cardiology: Percutaneous
and Mehmet C. Oz, MD 2004
Noncoronary Intervention, editedbyHoward
Cardiovascular Health Care Economics, edited by
C. Herrmann, MD, 2005 William S. Weintraub, MD, 2003
H C
ANDBOOK OF OMPLEX
P C
ERCUTANEOUS AROTID
I
NTERVENTION
Edited by
J S ,
ACQUELINE AW MD
Division of Cardiology, University of British Columbia,
Vancouver, BC, Canada
J. E E ,
MILIO XAIRE MD
Department of Interventional Cardiology, Instituto Nacional de
Cardiología “Ignacio Chávez,” Mexico City, Mexico
D S. L ,
AVID EE MD
Interventional Cardiology, Hillsboro Cardiology, Hillsboro, OR
J S. Y ,
AY ADAV MD
Department of Cardiovascular Medicine,
The Cleveland Clinic Foundation, Cleveland, OH
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Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1
eISBN 1-59745-002-2 ISBN13 978-1-59745-002-7
Library of Congress Cataloging-in-Publication Data
Handbook of complex percutaneous carotid intervention / edited by Jacqueline Saw ... [et al.].
p. ; cm. — (Contemporary cardiology)
Includes bibliographical references and index.
ISBN 1-58829-605-9 (alk. paper)
1. Carotid artery—Surgery. 2. Carotid artery—Stenosis. 3. Stents (Surgery) I. Saw, Jacqueline. II. Series:
Contemporary cardiology (Totowa, N.J. : Unnumbered)
[DNLM: 1. Carotid Stenosis—surgery—Case Reports. 2. Angioplasty,Balloon—methods—Case Reports.
3. Stents—Case Reports.WL 355 H2356 2007]
RD598.6.H36 2007
617.4'13—dc22 2006004982
D
EDICATIONS
To my husband, David, and our son, Evan, and my family, who make my life endeavors
worthwhile. And to my mentors in Interventional and General Cardiology (Drs. Donald
Beanlands, Deepak Bhatt, Irvine Franco, John Jue, David Moliterno, Eric Topol, and Jay
Yadav), for their guidance and support through my training, and for inspiring me to excel.
Jacqueline Saw, MD
To my wife, Karin, and my parents, Cristina and Emilio, with all my love and gratitude.
This book would not be possible without the teachings of Dr. Jay Yadav and the remark-
able Peripheral Intervention Staff at the Cleveland Clinic Foundation.
J. Emilio Exaire, MD
To Megan and my family for their love, support, and encouragement, and to the
interventional cardiologists at the Cleveland Clinic (especially Drs. Yadav, Franco,
Whitlow, Topol, and Bajzer) for their mentorship, friendship, time, and investment in
me.I would not be who I am and where I am without you.
David S. Lee, MD
To my family for their unfailing support and understanding, and to the interventional
cardiology fellows at the Cleveland Clinic for their curiosity and inspiration.
Jay S. Yadav, MD
v
P
REFACE
Since the first carotid angioplasty that was performed in 1980, this technique has
undergone tremendous modifications and improvements. Stents for the carotid artery
were utilized in the early 1990s, and emboli protection devices were introduced about
2000. Advances in equipment (guidewires, catheters, balloons, stents, and emboli pro-
tection devices) have improved the technical success and safety of carotid stenting. With
the recent SAPPHIRE publication revealing non-inferiority of carotid stenting compared
with carotid endarterectomy for high-risk surgical patients, this percutaneous procedure
is now considered a viable alternative to endarterectomy for these patients. In fact, the
FDA has approved carotid stenting for high-risk patients using the AccuLink™ stent and
AccuNet™ device (Guidant Corporation, Santa Clara, CA) in August 2004, and the
XactTM and EmboShieldTM system (Abbott Vascular Devices, Redwood City, CA) in
September 2005.
Increasing numbers of carotid stenting are being performed around the world, and
established interventionalists and trainees alike are seeking to be instructed in performing
this meticulous procedure. Unfortunately, there are insufficient well-established periph-
eral vascular training programs to meet this increasing demand. Only a small proportion
of current trainees are enrolled in fellowship programs with dedicated carotid interven-
tional training that perform high-volume extracranial carotid stenting; even fewer are
enrolled in programs that also partake in intracranial and acute stroke interventions. In
North America, this shortage of dedicated training programs leaves interested interven-
tionalists pursuing carotid stent training through short educational courses, and often
haphazard and limited “hands-on” experience in other institutions.
The purpose of our Handbook of Complex Percutaneous Carotid Intervention is to
provide a learning resource to complement the “hands-on” training of established inter-
ventionalists and trainees. This handbook is intended for various disciplines participating
in the management of patients with carotid and vertebral artery stenosis, including inter-
ventional cardiologists, vascular surgeons, interventional radiologists, and interventional
neurologists. The focus of this handbook is on percutaneous intervention of patients with
extracranial carotid artery stenosis. As interventionalists of the cerebrovasculature are
often faced with stenosis involving other cerebral vessels, we complemented our hand-
book with sections on percutaneous interventions of intracranial stenosis, vertebral artery
stenosis, and acute stroke.
We have provided a detailed introduction to the techniques of extracranial and intrac-
ranial, carotid, and vertebral interventions. We reviewed the indications, approaches,
equipment, and potential complications of these percutaneous interventions. As many
patients undergoing such procedures are elderly and high-risk with challenging anatomy,
we also provided some useful pearls and troubleshooting of technically difficult cases.
In addition, our section on challenging cases illustrates our approach to frequently en-
countered challenges at the Cleveland Clinic.
TheHandbook of Complex Percutaneous Carotid Intervention is also meant to pro-
vide a comprehensive review of the management of carotid artery stenosis. Thus, we have
vii
viii Preface
included chapters reviewing the epidemiology and significance of carotid stenosis,
medical therapy, noninvasive and invasive imaging of the carotid artery, and carotid
endarterectomy. In this current era of evidence-based medicine, we have also included
chapters reviewing sentinel studies supporting carotid endarterectomy and carotid stent-
ing.
Carotid stenting is an exciting and burgeoning field. It is often a challenging proce-
dure, which may expose patients to life-threatening complications. Its success as the
preferred revascularization therapy of high-risk patients is contingent upon low peripro-
cedural complications, which in turn is highly dependent on operator skills. As studies
comparing carotid stenting and endarterectomy for low-risk patients are completed, we
may see a further increase in the volume of carotid stenting. We hope that our Handbook
of Complex Percutaneous Carotid Intervention will provide a useful resource to guide
interventionalists through this challenging and important revascularization procedure of
the 21st century.
Jacqueline Saw, MD
J. Emilio Exaire, MD
David S. Lee, MD
Jay S. Yadav, MD
C
ONTENTS
Dedications ....................................................................................................................v
Preface ................................................................................................................. vii
Contributors...................................................................................................................xi
Companion CD........................................................................................................... xiii
P I C E
ART LINICAL XPERIENCE
1 Epidemiology and Significance of Carotid Artery Stenosis............3
Anthony Y. Fung and Jacqueline Saw
2 Medical Therapy for Carotid Artery Stenosis................................11
David S. Lee
3 Carotid Endarterectomy:
Techniques and Evidence-Based Medicine................................33
Joël Gagnon and York N. Hsiang
4 Carotid Angioplasty and Stenting Trials:
A Historical Perspective and Evidence-Based Medicine..........47
David S. Lee and Jay S. Yadav
5 Cerebrovascular Anatomy ..............................................................65
Ravish Sachar and Samir Kapadia
6 Noninvasive Imaging of the Carotid Artery...................................83
J. Emilio Exaire, Mikhael Mazighi,
Jacqueline Saw, and Alex Abou-Chebl
7 Cerebrovascular Angiography........................................................99
J. Emilio Exaire, Jacqueline Saw,
and Christopher Bajzer
8 Indications for Carotid Artery Stenting........................................111
Cameron Haery, Sharat Koul, and Deepak L. Bhatt
P II T C V A S
ART ECHNIQUES OF AROTID AND ERTEBRAL RTERY TENTING
9 The Approach to Extracranial Carotid Artery Stenting...............131
Jacqueline Saw and Jay S. Yadav
10 Equipment for Extracranial Carotid Artery Stenting...................147
Jacqueline Saw and J. Emilio Exaire
11 Emboli Protection Devices...........................................................159
Jacqueline Saw
12 Complications of Carotid Artery Stenting ...................................175
Jacqueline Saw
ix
x Contents
13 The Approach to Intracranial Carotid Artery Intervention..........189
Ivan P. Casserly and Jay S. Yadav
14 The Approach to Intracranial and Extracranial Vertebral
Artery Stenting .........................................................................211
J. Emilio Exaire and Jacqueline Saw
15 Endovascular Treatment of Acute Ischemic Stroke.....................229
Mikhael Mazighi, Qashim Bashir, and Alex Abou-Chebl
P III C C I P
ART HALLENGING ASE LLUSTRATIONS AND EARLS
16 Case: Left Carotid Artery Stenting with a Challenging
Type III Aortic Arch.................................................................249
Jacqueline Saw
17 Case: Stenting of a Tortuous Left Internal Carotid Artery..........259
J. Emilio Exaire
18 Case: Stenting of a Critical Internal Carotid Artery Stenosis
with String Sign........................................................................265
Jacqueline Saw
19 Case: Stenting of a Carotid Endarterectomy Patch Restenosis
and Aneurysm...........................................................................275
J. Emilio Exaire
20 Case: Carotid Stenting with Slow Flow
and Distal Embolization...........................................................283
J. Emilio Exaire
21 Case: Acute Stroke Intervention with a Large
Thrombotic Burden...................................................................289
Jacqueline Saw
22 Case: Left Internal Carotid Artery Stenting
in a Bovine Aortic Arch ...........................................................295
David S. Lee
23 Case: Right Carotid Artery Stenting via Right
Brachial Artery Approach........................................................305
David S. Lee
24 Case: Ostial Innominate Artery Intervention...............................317
David S. Lee
Index .......................................................................................................329
