Практика Shadowing: Experience with the pEGASUS for rescue stenting and treatment of ICAD - Изучайте разговорный английский с YouTube

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So good afternoon everybody.

We will start with Wallaby Phenox Symposium.

We have the chance of having René Chapeau presenting the experience with Pegasus in the treatment of ICAD and rescue stenting.

So René, please.

Thank you, Laurent.

Let's go.

What to know about Pegasus?

It's a laser cut stand, open cell.

So if it's open cell,

it means that it opens properly in the curves.

That's an important interest.

and it can be placed through 0165 or 0117 microcasters,

which is of course very interesting too.

The official indications are indeed not only aneurysms,

but also dissection and stenosis,

and I report on our use in high cadence stroke.

Just to have an idea how the stent behaves in compared to the other ones,

first here, all the four are the Pegasus,

and you see that 45,

the diameter and length play a certain role in the radial force.

If you compare with Leo is more than a Leo,

it's a bit more than an Atlas also.

Of course, a wingspan is a bit more powerful.

So our experience about 40 patients,

most of them in acute stroke,

acute stroke divided in ICAD.

So obviously food plays a given role and food can be a reason for treatment of stroke where you see this here,

this tight stenosis responsible of the symptoms where PTA is being done

and after PTA the stent is delivered with its three markers distally and proximally we systematically oversize.

There is no reason not to do it because opening is good also So if you oversize,

here's a six months follow up.

Same thing, a bit more distally,

also this patient arrived with important symptoms and you can understand that he has symptoms because he has a stenosis,

obviously some more clot.

So we systematically put a stent weaver to try to remove and indeed it is better.

If you see this and this,

there's less material that you're supposed to push inside the perforators.

And then if you see that it's still not so good and you fear that it may occlude,

sometimes we wait and you see that it occludes or if we feel uncomfortable,

stand is being placed after PTA.

And here we are with the device

which is in place with approximate distance markers and the six months follow up where it remained more or less stable.

So this is enough of course.

technique.

Why to do PTA before?

Very simple reason.

The stent have a very low stability.

And if you just deploy it,

if you try to cross again,

a PTA balloon has not the same ability to navigate in the microcaster and the chance to displace it is there.

So better to PTA before.

Two patients, obviously it was not enough.

And here's another acutely decompensated intracranial stenosis, which is there.

I think it's very difficult to know the proper size.

And I'm always interested when I discuss with my colleagues from the US,

Ednan, Ricardo, and a lot of others that are very pro coronary balloons, balloon mounted stents.

I never know the proper size to give.

And if I don't know,

I think it's very safe to put a first PTA balloon to look how it is and potentially to increase them.

The price of these balloons is very low.

The navigability is amazing

and then we adapt to what we see here is the result also after six months very stable

and it works on the right side

and guess what on the left side too so here the left ica with a similar picture you see first First,

it came as acute stroke,

so stent tree was placed through.

And then we PTA increasingly,

two, two and a half.

This is the result just after it.

And just by placing the stent,

you see that you gain a lot more.

The zoom is not exactly the same,

but still you see that it's much better.

So there is an added value to put a mechanical factor.

So here, one solitaire, two PTAs with two and two and a half,

and then the four and a half Pegasus inside.

Some patients have rescue stenting when you try to do a lot and it does not work.

And this here is a 48-year-old man,

a high NIH score, with this LEM1 where it should be simple and easy.

And our preferential way to proceed here is to do dual stent reverse,

which usually works unless it does not.

So first pass did not work.

Second pass did not work.

Then change, Sophia Solitaire did not work.

Fourth pass, Mono Solitaire does not work.

Fifth pass, Double Solitaire.

Six pass, I mean, you wonder what to do when in a 90-year-old patient you would not continue at 48.

The point is when to do rescue stenting,

because you know it's going to be rescue stenting,

but honestly, I don't know.

And it's not so simple.

Seventh pass where Batu, who made the treatments,

decided to go on for a first stand.

And then he got access to the other branch,

put the second one in the Y connection,

and the result is still amazing.

And this is the CT on the next day,

and the MR six months later.

where everything's not perfect.

100

We found a major instant stenosis.

101

One of the stents is occluded,

102

the other one is major tight.

103

So we went back, did some instant PTA with drug eluting balloons in the distance,

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smaller balloon, the proximal bit larger balloon.

105

And this is some few months later where you see that it's okay, it's good.

106

So definitely rescue stenting has a place,

107

but I think that defining is not so simple.

108

Dissection is also an interesting indication where I think there's no doubt

109

that the cause here for this patient to have a little distance stroke is this dissection with this here,

110

which is missing, where we put catch mini or time of catch mini here.

111

And then the Pegasus was placed.

112

This is immediately post.

113

This is, here are the markers.

114

Yes, the markers you see,

115

but you see them better when you have an arrow.

116

This is six months later,

117

where the hematoma is resolved and the vessels look good.

118

It's definitely the fact that here's a vessel which is angulated.

119

Makes sense to have something open cell, which is maximal flexible.

120

I mean, the other stands we have are good, too.

121

But the more the vessel has an important angulation,

122

I think the more it makes sense to go into the direction of open cell design.

123

No intraposital instant thrombosis, no distal vessel embolus that occurred.

124

Hemorrhagic complication that I'm going to show with this absolutely debatable treatment that was done by one of our colleagues.

125

I guess the clot must have been more proximal.

126

He still wanted to get it out.

127

Going distally, the stent river did not do the job.

128

And technically, it's absolutely no problem to go there with a micro catheter and deliver a stent river,

129

avoiding a stroke.

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So that's the nice part.

131

But the price for this is to put anti-GP to be 3A.

132

And the consequence here, this is the end result.

133

And the consequence is next day,

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a bleeding in a complete different territory.

135

But rescue stenting has a price,

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and I think that there's a lot of enthusiasm to do rescue stenting.

137

I think it must be still very reasonable.

138

I don't think that this is here the best indication.

139

And this is one of the drawbacks.

140

even not in the territory where the stent was placed

141

but I think we we know need to know precisely how frequently this takes place.

142

Elective stenting and PTA okay this is a regular condition this is straight vessel

143

so any stent would have done the job including this one but looks good.

144

Reconstruction is something we're doing more and more in chronically occluded vessels or subacutely occluded

145

where indeed it's interesting to think when should be the moment when we recanalize the vessel.

146

Because acutely we've got a high risk of having clots that move.

147

If you do it later,

148

usually it's because some issues are occurring.

149

And this lady, she's 55,

150

she had six months earlier an acute stroke where you see that the siphon is there,

151

the character that its origin is occluded,

152

and she was treated by aspiration, partial treatment.

153

And then she got a braided stent, which is quite thrombogenic.

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I'm not sure it's such a good idea to place this acutely,

155

which of course gives a good image.

156

But next day, stent was occluded.

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Patient was not too bad.

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It was lip like this.

159

And six months later, she came with ongoing TIAs this territory knowing

160

that the left ICA is occluded too and the left vert is occluded too.

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So she only has the right vertebral artery.

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What to do?

163

The problem is that she just has no right external carotid artery.

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She just has the left ICA giving something at the siphon.

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Everything's missing here.

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And from the origin, you still have a stump,

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which is indeed was quite helpful

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because navigating here with a triple system 8f guiding 8f uh 5f

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and then here terrible 35 allowed to go all through those

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vessels without too much of efforts the difficulty is not here

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the difficulty is once you get there to be able to re-enter

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and even if you take a cto wire that punctures

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when you're in a straight segment the chance to puncture outside is much higher than to puncture inside.

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So here in fact what helped us was to take a

175

cheek eye wire where we could get access again to the lumen

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and once it is done some PTA is being done

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and then extensive stenting is done extracranially with two wall stents and we did the intracranial part with a very long Pegasus

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and this is here the end result with two wall stands one protege

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and one and one precise and one Pegasus in the end.

180

This is same situation where a lot is missing

181

and in the end this is here's a disease spot treated with the Pegasus and here's six months follow-up.

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So as a conclusion we have the chance to have many self-explanable stands.

183

Self-explanable stands has advantage that when you have a nitri that varies in caliber, you can oversize.

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And if the vessel is not straight,

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open cell is of help.

186

Thank you.

187

Thank you.

188

Thank you very much, René ardan so there is a problem with 2b3a no question

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but i think a better solution that is now available

190

is kangaroo lord you can actually load patients on kangaroo lord at a much lower dose than coronary dose

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so you can actually even titrate what their pru is and

192

so that in theory it's still very early in theory should have a much lower risk profile than a 2B3A,

193

which I think is a big gun and really opens you up to all sorts of complications.

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Probably it's a bit unfair to show this complication because we've got a lot of patients where we did not have bleeding.

195

So all the question of proportion and it seems to be still rare.

196

Interestingly, the literature in the mid 2010s was very negative against GP2B3A.

197

Now there's an important literature saying it's very good.

198

I think to see once in a while a complication enables you to remain grounded.

199

But potentially can go along.

200

Just one question.

201

And then, is that a good point what you say?

202

But does that mean that we can also do that,

203

for example, for thrombolic complication during aneurysm treatment?

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Do you do that?

205

Do you replace Tirofiban or any GP2B3A by Congrelor,

206

or do you continue to use GP2B3A?

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Two scenarios.

208

One is emergent stenting.

209

Emergent stenting for aneurysm, emergent stenting for ICAD.

210

I think that's where Congrelor is really good.

211

The second situation is instant thrombosis, okay, coiling-associate thrombosis.

212

I think in that instance to be 3a is definitely the standard

213

so there will still used to be 3a

214

But for emergent cases where you're loading the patient It's fast

215

and it's it's very useful so we have a different experience

216

so even for thromboembolic complications during the procedure the kangaroo law is working very well for us

217

so So we have completely switched to Cangrelor in last few months for everything.

218

In fact, we are sometimes placing intrasacular and flow diverters,

219

and if there's a clot formation,

220

we give Cangrelor on top of Ticagrelor or Presagrelor, whatever you're giving.

221

Yes, but we're switching here.

222

I mean, the focus was on stroke,

223

and I think that whatever medication you give in stroke,

224

It will be a question of rate because no doubt that cangrelar will also induce some leadings,

225

but nothing against cangrelar.

226

Rene, in the last case that you show, was patient blind?

227

No. Because it had the cavernous origin of the ophthalmic.

228

So yes, because the CTO and the wires did not go to the lumen here and just continued straight.

229

So we were concerned, and luckily she did not.

230

Thank you.

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And one thing I observed,

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René, is that in instant stenosis,

233

you use a drug eluding balloon.

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Yes.

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Yeah.

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This is a practice that I have learned from here in Europe.

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And I don't interact with any instant event without a drug eluding balloon.

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Is this you do it for everyone?

239

It's extremely efficient.

240

I agree.

241

I agree.

242

Thank you very much, René.

243

Thank you.

244

Thank you, Laurent.

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