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More Advanced Techniques for Carotid Stenting
tients will need treatment with Atropine for potential bradycardia during angiopJasty of the native bifurcation and instrumentation of the carotid body. Generally 0.5 to Img of Atropine is given prior to balloon dilatation. Have vasodilators (such as Tridil, Nimodipine, or Nipride) immediately available, as well as pressors (such as Neosinephrine or Dopamine). Post-procedure management of blood pressure, heart rate, and the groin are of the utmost importance to prevent complications. Patients on Aspirin, Plavix, and fully-heparinized are ones that are likely to develop groin hematomas if groin management is not meticulously observed. Monitoring patients in an ICU or telemetry environment is usually helpful for several hours, especially in the high risk patient. A carotid stent procedure is not an entry-level examination. There are many pitfalls and appropriate preparation and planning is of utmost importance for a successful outcome. Choose easy cases when beginning your program and advance to more difficult cases cautiously. Close attention to detail and proper education should lead to a successful procedure and a happy patient. 9:25 a.m.
Avoiding and Managing Complications Leo Nelson Hopkins, MD SUNYAB Depm1ment Of Neurosurgery Buffalo, NY 9:40 a.m.
Search for the Holy Grail: Distal Protection, Is It the Answer? Chester jarmoloswki, MD Allegheny General Hospital Dept. Of Diagnostic Radiology Pittsburgh, PA 9:55 a.m.
TIPS From the Pros Klaus Mathias, MD Teaching Hospital of the City of Dortmund Dortmund, Germany 10:10 a.m.
Trials: What Do They Tell Me, and How Do They Help Me Get Started? Stephen R. Ramee, MD Ochsner Clinic Foundation New Orleans, LA 10:25 a.m.
CASE PRESENTATIONS: Simple Carotid Stent Cases with Panel Discussion 10:55 a.m.
COFFEE BREAK
P332
11:15 a.m.
More Advanced Techniques for Carotid Stenting john Laird, MD Washington Hospital Center Washington, DC 11:30 a.m.
Management of Carotid Injuries, Role of Covered Stents Dan'en Postoak, MD University Of Texas Health Science Center at San Antonio San Antonio, TX Carotid arterial injuries may be seen in blunt and penetrating trauma, as a complication of surgery or catheterization, or from malignancy due to invasive tumors and/or radiation injury. Traumatic dissections/transections, pseudoaneurysms, arteriovenous fistulas, and carotid blowouts have been described. Spontaneous dissections with or without pseudoaneurysm formation may also be seen. Blunt carotid arterial injuries have been reported at an incidence of 0.08-0.33% but with an aggressive screening program may be as high as 0.86% of blunt trauma admissions (1-3), Surgical treatment of carotid injuries is often not feasible due to the high location of many lesions. Medical management with anticoagulation may not be reasonable in a patient with multiple injuries and as much as 40% of dissections and many pseudoaneurysms do not "heal" with anticoagulation therapy and constitute a long-term risk of embolization or flow-related complications (2, 4). Over the past decade, endovascular techniques have advanced and give us another option in the treatment of carotid arterial injuries. Bare stents have been used to treat dissections and pseudoaneurysms of the carotid arteries (5, 6). Selfexpandable and balloon expandable stents have both been utilized. For dissections the stents have been placed within the narrowed area of the vessel. In patients with pseudoaneurysms the stent is placed across the neck of the pselldoaneurysm. With bare stents the pseudoaneurysm likely heals by redirection of blood flow and endothelialization of the stent with subsequent thrombosis of the pseudoaneulysm. In some cases the pseudoanellrysm does not thrombose or it will enlarge due to continued flow. In these instances the pseudoaneurysm can be excluded from the circulation by placing coils through the interstices of the stent using a microcatheter (7,8). As an alternative, the stent-coil procedure can be performed initially. Parodi (9) described the first stent-graft placement for carotid trauma in 1995. He treated a right common carotid artery pseudoaneulysm with a Palmaz stent covered with an autologous saphenous vein graft. Later that year, Nicholson and colleagues (10) described treatment of a left common carotid artery iatrogenic pseudoaneulysm with a self-expanding nitinol stent covered by polyester fabric (Craggstent, Mintec). Over the next few years
Avoiding and Managing Complications Leo Nelson Hopkins, MD SUNYAB Depm1ment Of Neurosurgery Buffalo, NY 9:40 a.m.
Search for the Holy Grail: Distal Protection, Is It the Answer? Chester jarmoloswki, MD Allegheny General Hospital Dept. Of Diagnostic Radiology Pittsburgh, PA 9:55 a.m.
TIPS From the Pros Klaus Mathias, MD Teaching Hospital of the City of Dortmund Dortmund, Germany 10:10 a.m.
Trials: What Do They Tell Me, and How Do They Help Me Get Started? Stephen R. Ramee, MD Ochsner Clinic Foundation New Orleans, LA 10:25 a.m.
CASE PRESENTATIONS: Simple Carotid Stent Cases with Panel Discussion 10:55 a.m.
COFFEE BREAK
P332
11:15 a.m.
More Advanced Techniques for Carotid Stenting john Laird, MD Washington Hospital Center Washington, DC 11:30 a.m.
Management of Carotid Injuries, Role of Covered Stents Dan'en Postoak, MD University Of Texas Health Science Center at San Antonio San Antonio, TX Carotid arterial injuries may be seen in blunt and penetrating trauma, as a complication of surgery or catheterization, or from malignancy due to invasive tumors and/or radiation injury. Traumatic dissections/transections, pseudoaneurysms, arteriovenous fistulas, and carotid blowouts have been described. Spontaneous dissections with or without pseudoaneurysm formation may also be seen. Blunt carotid arterial injuries have been reported at an incidence of 0.08-0.33% but with an aggressive screening program may be as high as 0.86% of blunt trauma admissions (1-3), Surgical treatment of carotid injuries is often not feasible due to the high location of many lesions. Medical management with anticoagulation may not be reasonable in a patient with multiple injuries and as much as 40% of dissections and many pseudoaneurysms do not "heal" with anticoagulation therapy and constitute a long-term risk of embolization or flow-related complications (2, 4). Over the past decade, endovascular techniques have advanced and give us another option in the treatment of carotid arterial injuries. Bare stents have been used to treat dissections and pseudoaneurysms of the carotid arteries (5, 6). Selfexpandable and balloon expandable stents have both been utilized. For dissections the stents have been placed within the narrowed area of the vessel. In patients with pseudoaneurysms the stent is placed across the neck of the pselldoaneurysm. With bare stents the pseudoaneurysm likely heals by redirection of blood flow and endothelialization of the stent with subsequent thrombosis of the pseudoaneulysm. In some cases the pseudoanellrysm does not thrombose or it will enlarge due to continued flow. In these instances the pseudoaneurysm can be excluded from the circulation by placing coils through the interstices of the stent using a microcatheter (7,8). As an alternative, the stent-coil procedure can be performed initially. Parodi (9) described the first stent-graft placement for carotid trauma in 1995. He treated a right common carotid artery pseudoaneulysm with a Palmaz stent covered with an autologous saphenous vein graft. Later that year, Nicholson and colleagues (10) described treatment of a left common carotid artery iatrogenic pseudoaneulysm with a self-expanding nitinol stent covered by polyester fabric (Craggstent, Mintec). Over the next few years