ISET 2006 Carotid Stent Tips, Tricks and Trial Results

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WELCOME
Hilton Harrisburg, September 2007
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Let us separate fact from fiction
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The Purpose of Stent Geometry

• Supports tissue and plaque
• against vessel wall
• Optimizes scaffolding
• Angiographic outcome
• Prevents Recoil
• Will not fracture over time

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Stent Design Features Radial Segments
Connecting Links
Pre-deployment shape
Post-deployment shape
Connecting links across every crown significantly
decreases the flexibility of the stent
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Stent Design Features Radial Segments Connecting
Links
Designs of this type are called open cell designs

• Increases the size of the cell

• Compromises scaffolding to increase stent
  flexibility

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Good for open cell
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Good for closed cell
LUCAS, CARL
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Cell Design - CAS
Epd. 100u
Proximal
Distal
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Wallstent Experience

• Klaus Mathias
• 2001 Data
• 680 Wallstents
• 3.5 stroke and death

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Vulnerable plaque
Great risk of early post-procedural embolisation

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apposition, conformability and scaffolding
matters
Closed cell ws has micro-motion and free edges
A. Nexstent B. Wallstent C. Precise Stent
A
B
C
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Stent designVessel apposition
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3
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Carotid Wallstent 9.0 x 30 mm
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CAPTURE 3000 vs. EXACT 90030 day Outcomes All
Patients
Hierarchical Includes only the most serious
event for each patient and includes only each
patients first occurrence of each event
Preliminary Results
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CAS PMS what have we learned?No evidence of
influence of Stent systems

• Update on the results of contemporary Post Market
  Studies EXACT and CAPTURE 2

All stroke/death
ALL PATIENTS EXACT n 2239 CAPTURE 2 n2070
SYMPTOMATIC EXACT n222 CAPTURE 2
n205
ASYMPTOMATIC EXACT n2014 CAPTURE
2 n1863
Hierarchical Events Includes only the most
serious event for each patient and includes only
each patients first occurrence of each event.
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Frankfurt Registry
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Ischemic Events During Procedure
()
Events
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Ischemic Events Until Hospital Discharge
()
NS
NS
NS
NS
Events
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Microemboli during CAS
Pinero et al. AJNR 2006 27 1338-1345
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Most embolic particles are less than 100m
Neither Stents nor Filters Control these Emboli
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600
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Embolic phenomenon during CAS
Pre CAS
Post CAS
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Stent Conformability Comparison
Closed Cell stent
Open Cell helical stent
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Precise self expanding stent with nitinol
nanoporous coating for controlled drug elution
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5. Eva-3s closed cell didnt help
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SPACE trial - 70 closed cell stent
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Common carotid stenosis Post-stenting
Movie loop, with posterior part of the stent
removed for better visibility of the broken strut
Strut fracture, stress at tapered convexity??
Axial cross-sections
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Unstable Plaque
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Stable Plaque
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THIS IS THE PROBLEM
ID (IVUS Defined) TCFAs
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JR4 Needed
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Vulnerable Plaque proximal to high grade stenosis
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Stent erosion of Vulnerable Plaque with rupture
Is vulnerable plaque the culprit in procedural
strokes?
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Longer stent to cover the vulnerable plaque
Would covered stent be more appropriate?
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Outcomes are affected by

• Anatomic Factors
• Lesion anatomy
• Type A,B,C lesions
• Aortic arch types
• Plaque analysis and vulnerability
• Stent Design
• Filter efficiency
• Proximal flow control

• Patient factors
• Patient selection
• Operator experience
• Octogenarians
• Symptomatic patients
• Length of procedure
• Commorbidities
• Prior stroke

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Conclusion

• There are 14 to 20 factors that influence CAS
  outcomes
• Stent design is only one, and the literature
  doesnt seem to care which one- open or closed!!

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WELCOME
Hilton Harrisburg, September 2007