跟讀練習: Carotid Artery Stenting - Tips & Tricks - 通過影片學習英語口語

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In this video, we will discuss challenges and difficulty we faced during one of our carotid artery stenting case.

Patient is 58 year male,

presented with acute onset of mild weakness of left upper and lower limb.

He has many risk factors responsible for atherosclerosis like hypertension,

hypercholestremia, diabetes and he is a chronic smoker.

MRI brain showed abnormal T2 hyperintensity at coronary later displaying diffusion restriction suggestive of acute infarct.

This location of infarct suggests deep watershed territory infarct between the perforator arteries and superficial cortical arteries.

Right carotid angiography showed near total occlusion of right internal carotid artery with poor intracranial flow

and there is retrograde reformation of the ophthalmic artery via middle meningeal artery collaterals.

This angiographic findings suggest hemodynamic compromise of right cerebral hemisphere.

So we plan for carotid artery stenting under embolic protection device in this case.

The procedure could be divided into following steps.

Carotid access, measurement and choosing the appropriate carotid stent and filter size,

pre-dilatation, embolic filter device deployment, stent deployment and post-dilatation.

These are the hardware we used in this case.

Safe carotid access is the first step of carotid artery stenting procedure.

Always look for unfavorable arch in CT angiography images.

We placed 8F short sheet at groin and taken 6F long sheet over diagnostic catheter under fluoroscopy to right common carotid artery.

By this technique we could avoid the exchange maneuver.

This is the right common carotid artery injection via long sheet.

We obtained measurement.

Based on our measurement we choose 6 to 8 millimeter tapered stent from abort

and we also use a smaller size of available embossed shield.

As the stenosis is very tight

and crossing profile of filter device is larger we plan to pre-dialect the stenosis using the coronary balloon.

We use 1.4 BMW coronary wire and 2.5 mm size of the coronary balloon to dilate the stenosis.

There is significant improvement of the lumen after the angioplasty.

Now we cross the lesion using O.1.4 bare wire of the filter device.

It has a 3 cm distal radio opaque tip which we kept at C1 vertebral level.

Now AmboShield filter device is taken over the O14 wire.

Filter is deployed at C2 vertebral level.

Filter device should be placed in the straight segment of the carotid artery

and should be more than 2 cm distal to the distal landing zone of carotid stent.

Filter has migrated proximally to the level of stenosis during removal of its delivery catheter.

To understand proximal migration of the filter device,

we need to know the filter design.

Ambushil filter device has umbrella like nylon membrane and nitinol frame.

This nylon membrane has multiple micropores to allow the blood perfusion and to trap the embolic material.

It has two radiopic markers at the proximal and the distal end.

AmboShield filter device is a monoreal system pre-loaded on O14 wire.

AmboShield is not fixed on this wire,

it is freely movable on this wire and because of this there is a risk of intracranial dislodgement of this filter device.

To avoid any intracranial migration of AmboShield filter device,

there is a focal step design on the bare wire distal to the filter.

This focal step is 019 and which will act as a distal limit of the filter device.

So when this distal 019 step at the bare wire is in contact with the distal marker of the filter device,

it might drag filter proximally

if the bare wire is pulled by mistake during the exchange maneuver and this is exactly what had happened in this case.

We gently push the filter device upward using the retrieval catheter.

Now stent delivery catheter was taken over O14 bare wire.

Distal nose of the stent delivery catheter has further pushed the filter device to the desired location.

Precise location of stent was confirmed by guide catheter injection.

was deployed and delivery catheter was removed.

Check angiography showed residual waste so we performed angioplasty of the residual stenosis using 4.5 mm coronary balloon.

Only after angioplasty, there was complete occlusion of internal carotid artery.

The possibilities could be that the filter device might have occluded due to the trapped embolic materials

or acute distant thrombosis or carotid artery dissection and vasospasm.

We immediately checked ACT which was within desired level.

We repeated 1000 units of heparin bolus.

We gave loading dose of agrastat via guide catheter and started IV infusion.

We also performed aspiration of the thrombus using coronary aspiration catheter.

After all these efforts, check angiography showed some restoration of the flow in the internal cuted artery and across the filter.

So we decided to retrieve the filter device.

While retrieving the filter device,

we only partially engaged the portion of the filter device inside the retrieval catheter to prevent escape of any trapped emboli.

After removing the filter device,

complete flow is restored in the internal carotid artery and the stent.

Gross examination of the filter device showed trapped embolic materials.

So we could conclude

that the sudden occlusion of the carotid artery after balloon angioplasty

is most likely due to release of lot of embolic materials

which were trapped by the filter device and causing the complete flow arrest across the carotid artery.

Once we remove this filter device the flow is restored.

Final angiogram showed complete revascularization of the internal carotid artery and good restoration of the intracranial circulation.

This also imply the importance of use of filter device during carotid artery stenting procedure.

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跟讀練習: Carotid Artery Stenting - Tips & Tricks - 通過影片學習英語口語

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