G. ?. T.

1
CAROTID STENTING TEXNIKH
G?O?G?S ????????S ???????S ?.?.T.
G. ?. T. G. G????????S -
?GG??????????G??? ????? - ?? ???????G???
??????? ?.?.T.
2

• ? ?e????????? t?? ?a??t?d?? (CEA ? CAS) apa?te?
  s??d?asµ?
• ?????? ep?p?d?? ?e???t???? ?at??t?s??
• te?????? a?t??t?ta?
• e??a? ped?? µ?de????? ??????
• e?e???t??? p??stas?a ep????? as?e???? ??a t?
  µ???d?, ??????, ???s?µ?p????µe??? te??????
• pa??t??? p??stas?a d?e??e???t??? p??stas?a
  eµß???sµ??
• epa???? pe??e??e???t??? ?????? (2
  a?t?a?µ?peta??a??)
• ??????S G?OS? ????????S/ ???????? ????????S?S
• Parlani G, De Rango P, Verzini F, Cieri E,
  Simonte G, Casalino A, Manzone A, Cao P. Safety
  of Carotid Stenting (CAS) is Based on
  Institutional Training pe than Individual
  Experience in Large-volume Centres.
• Eur J Vasc Endovasc Surg. 2013 Mar 4. doipii
  S1078-5884(13)00120-2. 10.1016/j.ejvs.2013.02.003.
  
• Timaran CH, Mantese VA, Malas M, Brown OW, Lal
  BK, Moore WS, Voeks JH, Brott TG CREST
  Investigators. Differential outcomes of carotid
  stenting and endarterectomy performed exclusively
  by vascular surgeons in the Carotid
  Revascularization Endarterectomy versus Stenting
  Trial (CREST).
• J Vasc Surg. 2013 Feb57(2)303-8.

3

• ??sa???e??
• ?µes? te????? (?d??? ?a?et??a)
• µ???? 11e?. e???? 6-8Fr
• 25 35e?./?p?st????? (e????s?/st???s? ?a??????)
• ???es??p??? te????? (µa??? ??????)
• ????? 90e?. e???? 6-8Fr

4

• ??sa???e??
• ?µes? te????? (?d??? ?a?et??a)
• µ???? 11e?. e???? 6-8Fr
• 25 35e?./?p?st????? (e????s?/st???s? ?a??????)
• ???es??p??? te????? (µa??? ??????)
• ????? 90e?. e???? 6-8Fr

S???? ?????S? ? ??G? S????? S??G??? ?G??S? ??
???????S???? F?S????G??? ???? 5000 UI HEP/
1000ml BOLUS 5000 UI ? ACT 250
5

• ?d??? s??µata
• ?d??f??? s??µa 0.035??, µa?a?? (p.?. soft
  Terumo), ?e?aµµ???? ?a? e??aµpt?? ?????
• ap?f??? t?a?µat?sµ?? st? t???
• - ?µes? te????? t? s??µa staµat? a?st??? p???
  t?? ?a??t?d??? d??asµ? ?a? p????e?ta? ? ?d????
  ?a?et??a?
• - ???es??p??? te????? ? d?????s? ??????
  ?a??t?da? t? s??µa p????e?ta? st?? ??? ?a??t?da
  ?a? e?a???sseta? µe s????? (p.?. Stiff Terumo) ?
  ?p??s????? ?d??? (p.?. super stiff Amplatz) s??µa
  ?ste ?a pa???eta? ? apa?t??µe?? ?p?st????? ??a
  p?????s? t?? ???a???? ? ?d???? ?a?et??a
• ???e?t???? ?a?et???asµ?? ?s? ?a??t?da? 0.014??
• (?at? p??t?µ?s? extra support)

6

• ???e?t???? ?a?et???asµ?? (1.5 2 ???d???? ????)
• ?GG???G??F?? ???????? ????? - ????S ????????
  ?????
• (pigtail d??aµ??? d?ep?ped?)
• - s??µa /?aµp???t?ta
• - ß?e??? t?p??
• - ßa???/?p?s??a ??f?s?
• - epasß?st?s?/ p???e?
• - st???s? e?f?se??

7

• ???e?t???? ?a?et???asµ??
• ?GG???G??F?? ???????? ????? - ????S ????????
  ?????
• (pigtail d??aµ??? d?ep?ped?)
• ????? ???????? ?????
• I II III IV

1.5 2cm
gt2cm
8

• ???e?t???? ?a?et???asµ??
• ROADMAP
• ?µes? te?????
• ??e??e?t?µata ?d???? ?a?et??a 80 90cm
• µa?a?? ???? µe p??d?aµ??f?µ??? s??µa ?a?
  s?????te?? s?µa (a??? ????te?? s????? ap? t?
  ??????)
• ?ate????t???t?ta t?? ?????
• T??? t?p?? ? ? ??
• Headhunter
• 40? ? multipurpose - 8Fr
• ???? t?p?? ???
• ??e??/ Bovine
• Hockey stick - 8Fr

9

• ???e?t???? ?a?et???asµ??
• ROADMAP
• ???es??p??? te?????
• ??e??e?t?µata
• ? a??e????af???? ?a?et??a? (4 5Fr, 120cm) ??e?
  p?? µa?a??/at?a?µat??? ????
• ? p?????s? t?? ???a???? (7Fr 90cm) µe t?
  d?ast???a t?? e??a? p?? at?a?µat??? ap? t?
  p??asµa ?d???? ?a?et??a
• T??? t?p?? ? ? ??
• Headhunter, Vertebral
• Simmons 1, JB1
• ???? t?p?? ???
• ??e??/ Bovine
• Simmons 1 , JB 2

10

• ???e?t???? ?a?et???asµ??
• ROADMAP
• ???es??p??? te?????

11

• ???e?t???? ?a?et???asµ??
• ROADMAP
• ???es??p??? te?????

12

• ???e?t???? ?a?et???asµ??
• ROADMAP
• ???es??p??? te?????

13

• ???e?t???? ?a?et???asµ??
• ROADMAP
• ???es??p??? te?????

14

• ???e?t???? ?a?et???asµ??
• ROADMAP
• ???es??p??? te?????

15

• S?G???S? ??????O? ?????????? ??T??????S???

????S?????? ???S?
?sfa??ste?? ?a? ap?te?esµat???te?? se a?at?µ???? d?s????e? ?sfa??? ?a? ap?te?esµat??? se e??????? ?a?et???asµ???
?a??te?? µetaf??? a??????? e????e?a? st?? e?a??a??/p?????s? ?????? Se ßa?? t??? e??a? p??a?? ? d?s????a e?a??a???/p?????s?? ??????
?pa?te?ta? p??ta 0.035??s??µa st?? ECA 0.035??s??µa st?? ECA µ??? st?? µetat??p? sepush and pull ?µ?a?????? te?????
???a? p??a?? ? ?efa???? a?ad?p??s? d?????µ???? ?a??t?da? - ?e?d?ß??ß?
7 Fr ????? ?ate????t???t?ta ????? 8Fr ??a??et??? ?ate????t???t?ta ?????
16

• S?G???S? ??????O? ?????????? ??T??????S???

????S?????? ???S?
?sfa??ste?? ?a? ap?te?esµat???te?? se a?at?µ???? d?s????e? ?sfa??? ?a? ap?te?esµat??? se e??????? ?a?et???asµ???
?a??te?? µetaf??? a??????? e????e?a? st?? e?a??a??/p?????s? ?????? Se ßa?? t??? e??a? p??a?? ? d?s????a e?a??a???/p?????s?? ??????
?pa?te?ta? p??ta 0.035??s??µa st?? ECA 0.035??s??µa st?? ECA µ??? st?? µetat??p? sepush and pull ?µ?a?????? te?????
???a? p??a?? ? ?efa???? a?ad?p??s? d?????µ???? ?a??t?da? - ?e?d?ß??ß?
7 Fr ????? ?ate????t???t?ta ????? 8Fr ??a??et??? ?ate????t???t?ta ?????
Morph (Biocardia)
PITON
17

• S?G???S? ??????O? ?????????? ??T??????S???

????S?????? ???S?
?sfa??ste?? ?a? ap?te?esµat???te?? se a?at?µ???? d?s????e? ?sfa??? ?a? ap?te?esµat??? se e??????? ?a?et???asµ???
?a??te?? µetaf??? a??????? e????e?a? st?? e?a??a??/p?????s? ?????? Se ßa?? t??? e??a? p??a?? ? d?s????a e?a??a???/p?????s?? ??????
?pa?te?ta? p??ta 0.035??s??µa st?? ECA 0.035??s??µa st?? ECA µ??? st?? µetat??p? sepush and pull ?µ?a?????? te?????
???a? p??a?? ? ?efa???? a?ad?p??s? d?????µ???? ?a??t?da? - ?e?d?ß??ß?
7 Fr ????? ?ate????t???t?ta ????? 8Fr ??a??et??? ?ate????t???t?ta ?????
PITON (Medtronic/ Invatec)
18

• ?????S? ?????????O? ???S?S ???????S
• ?µ?a?????? te?????/ ???s? a??e????af????
  ?a?et??a (120cm)
• ??????s? s??µat?? ?a? a??e????af???? ?a?et??a
  st?? ??? ?a??t?da
• ?d??? s??µa 0.035??st?? ????? ?a??t?da
• Buddy wire de?te?? s??µa 0.014??st?? ???
  ?a??t?da
• ????????S? ?? ?????????? ??S?????
• S??????? ???????OS? ??? ?? ??S ??? ???????S
• ??T? ?????G? ?ST??O? / ???????O?
• ??????S ?O? 10?
• ????????? ???S????S?
• ???S??S? ??? ??? ?????F???

19

• ?????????? S??? ??T??????S?? ??S ?SO
  ???OT?S? F??????/ S?S????S ???S??S??S
• ?. ??? ?. G???? 0.0014 G.
  G???? 0.0014
• 
  Buddy wire st?? ?s?
• ?fa??es? ? t??????st?? µe???? ap?s??s? t??
  de?te??? s??µat?? ??a ?a e?e???e? ? p????? epaf?
  t?? f??t??? st? ?a??t?d??? t????µa

20

• ?????????? S??? ??T??????S?? ??S ?SO
  ???OT?S? F??????/ S?S????S ???S??S??S
• S???OS? gt 80 ? ?????O???? ?????
• ??????????? ?? ?????????? S???? ??? ? ???OT?S?
  ??? ????????? J ????? ?? ?????T??S? ?? ????????
  ????O??
• ???a?? ????a?/p??ß???? a?t???s??p?s??
• ???s??? ?a µ?? ap????e? ? ?a?et??a?/?????? st?
  t???
• ??????S????

21

• S?S????S ?G??F?????S ???S??S??S
• ??O ???S??S??
• ???????S??S ?SO ???O????S
• PERCUSURGE GUARDWIRE (MEDTRONIC)
• µpa???? f??t?µ??? se 0.014??s??µa
• s??????? e??te???? d??µet??? 0.036 0.91mm
• s??µa a?t???s??e??, d?aµ??f?s?µ?, ?ate?????µe??
• s?s?e?? p????s?? µpa?????? ap? 3 6mm
• s?s?e?? a?a???f?s?? 15 ml (monorail)
• 1 3 a?a???f?se??

22

• S?S????S ?G??F?????S ???S??S??S
• ??O ???S??S??
• F?????
• ANGIOGUARD (CORDIS)

t?p?? p??f??t?µ??? se s??µa 0.014?? ?µ??e?t?? µe ??t? s??µata
d??µet??? ?a?et??a 3.2 3.9 Fr
d??µet??? f??t??? 4 7mm
?????/ p???? p??????e????/ 100µm
23

• S?S????S ?G??F?????S ???S??S??S
• ??O ???S??S??
• F?????
• EMBOSHIELD NAV6 (ABBOT VASCULAR)

t?p?? a?e???t?t? s??µa 0.014?? ?µ??e?t?? µe ??µ?? s??µata
d??µet??? ?a?et??a 2.8 3.2 Fr
d??µet??? f??t??? 2.5 4.8mm, 4 7mm
?????/ p???? ??????-?d??f???- a?t????µß?t???/ 120µm
24

• S?S????S ?G??F?????S ???S??S??S
• ??O ???S??S??
• F?????
• RX ACCUNET (ABBOT VASCULAR)

t?p?? p??f??t?µ??? se s??µa 0.014?? ?µ??e?t?? d???? stent
d??µet??? ?a?et??a 3.5 3.7 Fr
d??µet??? f??t??? 4.5, 5.5, 6.5, 7.5mm
?????/ p???? p??????e????/ 125µm
25

• S?S????S ?G??F?????S ???S??S??S
• ??O ???S??S??
• F?????
• FILTERWIRE EZ (BOSTON SCIENTIFIC)

t?p?? p??f??t?µ??? se s??µa 0.014?? ???e?t?? µe nitinol da?t????
d??µet??? ?a?et??a 3.2 Fr
d??µet??? f??t??? 3.5 5.5mm
?????/ p???? p??????e????/ 110µm
26

• S?S????S ?G??F?????S ???S??S??S
• ??O ???S??S??
• F?????
• SPIDER (EV3 COVIDIEN)

t?p?? ??e???t?t? s??µa 0.014? ?a? e?a??a?? se ???e?t?? ?a???? p??f??t?µ??? se s??µa 0.014??
d??µet??? ?a?et??a 2.9 Fr
d??µet??? f??t??? 3, 4, 5, 6, 7mm
?????/ p???? nitinol d??t??t?/ ??? 50µm
27

• S?S????S ?G??F?????S ???S??S??S
• ?GG?S ???S??S?? (???S???F? ???S)
• ???????? ???????S???
• NEUROPROTECTION SYSTEM (GORE)
• 2 a?e???t?ta d?ate???µe?a µpa????a se ?????? 9Fr
• s??e??? pa??t??? ? e?e???t??? a??st??f? ??? t??
  ?s? ??????s? t?? µe ?????? 6Fr (µ???a?a f?.
  f??t?? 180µm)
• e?e???? a?a???f?s? µet? ap? ???e ?e???sµ? st?
  p??a?
• s??d?asµ?? µe f??t??

28

• S?S????S ?G??F?????S ???S??S??S
• ?GG?S ???S??S?? (???S???F? ???S)
• ???????? ???????S???
• MOMA (MEDTRONIC)
• 
  7.2 cm
• 
  
• 2 a?e???t?ta d?ate???µe?a µpa????a 13mm
  6mm(???)
• ?????? 100cm 8/9Fr µe a??? 5/6Fr
• e?e???? a?a???f?s? µet? ap? ???e ?e???sµ? 60ml
  st? p??a?
• s??d?asµ?? µe f??t??

29

• S?S????S ?G??F?????S ???S??S??S
• ???????? ?????G?S ??T????
• F????? ? ???????S??S/???S???F? ???
• F????? ?? ????? S???????? ? ?????OS? ???
  ???SF?????? (ete??p?e??? ap?f?a?? ap?as?a
  Willis)
• ???????S??/ ???S???F? ??? S? ???????? ??????? G??
  ?T?????????S?? (a??????? p???a, crescendo TIAs)

30

• S?S????S ?G??F?????S ???S??S??S
• ???????? ?????G?S ??T????
• F????? ???????? ? ?????????
• ???F?G? ??????/????????? ?O???
• ????????? G?? ????T???S? S? ??T? ????? (p.?.
  ??O?????? ?????)
• ???????? G?? ????T???S? S? ?????OS??S ? ???? ??
  S?FO???

31

• S?S????S ?G??F?????S ???S??S??S
• ???????? ?????G?S ??T????
• ?GG?S ? ??O ???????S??S/???S???F? ???
• ??O ???????S??S ?? ? ???????? ????? ??????T?????
  ??? ??T? ????? ?SO ???O????S
• ?GG?S ???????S??S
• ?? ? ???????? ????? ??????T????? ??? ??G???
  ?????OS? ?SO ???O????S
• S? ?F?????S ???F?????S
• (S? ?????????? G?? ??????????????)

32

• ??????S????
• ???? ?? ??????OS ??????????
• ????? ??? ?GG?S ???????S??
• S? ?F?????S ???F?????S
• (??? ??????????S G?? ??????????????)
• ??????? 30mm / 2.5 4mm/ 6 8 Bar/Atm
• 1 Bar 0.986923267 Atm
• CUTTING BALLOON

33
S?????G??? ?????G?S STENT
?e????? ?a?a?t???st??? COBALT mesh NITINOL Open cell NITINOL Close cell
??????s? gt15 lt15 lt15
??p?ast?t?ta -
???sa?µ???
??????
??t????? d??aµ?
??t????? a?t???
34

• S?????G??? ?????G?S STENT
• ???????S ?????????
• µa???? ?a? a???????? ? µ??t?? ß??ße?
• e??e?asµ? µa???? ?a? d?????µ???? ß?aß??
• d?s????e? p?????s??/?p?st??????
• Carotid Wallstent - Boston
• NITINOL
• ß?a?e?e? (lt15mm) ?a? epasßest?µ??e? ß??ße?
• d?at???s? a?at?µ?a?
• a???ß?ste?? t?p???t?s?

35

• S?????G??? ?????G?S STENT
• ???????S ? ????S??S ??????

Open Close Hybrid
36

• S?????G??? ?????G?S STENT
• ???????S ? ????S??S ??????S
• ?????t? ??a d?????µ??e? epasßest?µ??e? ß??ße?
• ??e?st? ??a a???????? ?a? µ??t?? ß??ße?
• ???t? ??a s??d?asµ?

Open cell Close cell Open close
Acculink (Abbot) Xact (Abbot) Cristallo Ideale (Invatec- Medtronic) ?????t? e???? ?a? ?p? ??e?st? st? µ?s? tµ?µa
Precise (Cordis) Adapt (Boston) Cristallo Ideale (Invatec- Medtronic) ?????t? e???? ?a? ?p? ??e?st? st? µ?s? tµ?µa
Protege (ev3-Covidien) Cristallo Ideale (Invatec- Medtronic) ?????t? e???? ?a? ?p? ??e?st? st? µ?s? tµ?µa
Sinus-Carotid (Optimed) Cristallo Ideale (Invatec- Medtronic) ?????t? e???? ?a? ?p? ??e?st? st? µ?s? tµ?µa
Zilver 518RX (Cook) Cristallo Ideale (Invatec- Medtronic) ?????t? e???? ?a? ?p? ??e?st? st? µ?s? tµ?µa
Vivexx (Bard) Cristallo Ideale (Invatec- Medtronic) ?????t? e???? ?a? ?p? ??e?st? st? µ?s? tµ?µa
37

• S?????G??? ?????G?S STENT
• ??T? ? ?O????
• ???? ??a µ????? est?a??? ß??ße? ?s? ? ?????? ?
  ??a ß??ße? d??asµ?? µe µ???? d?af??? d?aµ?t???
  ?s?/??????
• ?????? ??a ß??ße? ??a ß??ße? d??asµ?? µe µe????
  d?af??? d?aµ?t??? ?s?/?????? (gt4mm)
• p???de?t??? ??????t?ta
• Acculink, Xact (Abbot), Sinus-carotid (Optimed)
• d???????
• Protege (ev3)

38

• S?????G??? ?????G?S STENT
• ?????G? ??G?T??S
• NITINOL
• ????????S (max oversizing 1mm)
• ????S (5mm above below)
• COBALT MESH (ß?????s?)
• 30-50mm µe?a??te?? µ????

39

• ???OT?S? ??? ?????? T?S? STENT
• ?GG???G??F???S ???G??S (8Fr)
• ???? ??? ???? ??? ???????

40

• ???????S???? (???d???? eµß???sµ?? -
  ß?ad??a?d?a?)
• ????? µpa?????? 20mm
• ???µet??? µpa?????? lt55mm
• ??ast??? µ??? µ?sa se stent
• ??a f??? a??e? 15 ?p??e?µµat??? st???s?
  ap?de?t?
• ?a?e?a s?µp?es? ap?p?es? / ???µast??? p?es?
  (8Atm)
• St??ß???s? se e?????s? e?t?? stent af??eta? ??
  ??e?
• St???s? / e??tt?s? ???? st?? ??? af??eta? ?? ??e?
• Atropine (0.5 1 mg)
• ?GG???G??F?? ???? ?? ???????S????
• (ap?s??s? µpa??????)

41

• ???????S???? (???d???? eµß???sµ?? -
  ß?ad??a?d?a?)
• ????? µpa?????? 20mm
• ???µet??? µpa?????? lt55mm
• ??ast??? µ??? µ?sa se stent
• ??a f??? a??e? 15 ?p??e?µµat??? st???s?
  ap?de?t?
• ?a?e?a s?µp?es? ap?p?es? / ???µast??? p?es?
  (8Atm)
• St??ß???s? se e?????s? e?t?? stent af??eta? ??
  ??e?
• St???s? / e??tt?s? ???? st?? ??? af??eta? ?? ??e?
• Atropine (0.5 1 mg)
• ?GG???G??F?? ???? ?? ???????S????
• (ap?s??s? µpa??????)

42

• ????S?? ???S S??? ?SO ? S?? F?????
• S??S??S (s?????? ap? µeta????s? t?? f??t??? p??
  ??eta? µet? t?? ap?s??s? t??/ 100-400µg Nitro)
• ????OS? F?????? ? a?a???f?s? µe ?a?et??a µ???? ?a
  e????eta? ?a?a?? a?µa ?a? µet? ap?s??s?
• T????OS? ????????S (p??a?? ?a? ap? t?? d??
  ??e??)? s?s?e?? a?ast??f?? ???? ?a? µet? ap?s??s?
• ????????S F??????????? ?????????S??
• ?????S???G?? ???????S
• ????? T????OS? STENT - HIT
• Stotts G, Skinner C, Code C, Lawrie G, Lesiuk H,
  Lum C. Acute stent occlusion due to heparin
  induced thrombocytopenia and thrombosis during
  carotid artery stenting. J Neurointerv Surg. 2012
  Nov4(6)e34.

43

• ?????OS? - ????S?? ???S S??? ?SO
• ????O??S??S S?? ???? ??? STENT
• s?????? ????? µe??s? ????/ ep??tas? stent
• ????O??S??S S?? T?S? ??? F??????
• d?at???s? s??µat?? st?? a???? a???/ µpa????

44

• ???S??S? F??????
• GO??OS? STENT ? ??????? ??????
• ??T??????? G?? ?G??S??OS? ??? ??T????? ???S??S?S
• (fish scaling phenomenon)
• ???S??S? ??T????? S??? ????? ???????????
  S???F? ??S ??F???S
• ??T???S?? STENT ?GG???? ????????OT?S?
• ???????S???? ?GG???G??F???S ??T?????S
• T???S? S??????S / ??O???? F??????
• ? ?????S? ?? ???G?? ? ?????????

45
?????? ?GG???G??F?? ????????? ??????????
???? ???S??S? ??O? ?O? ????O? T???????/
??T????? ???S? (20?) ?????S?
46

• ????????S ???????S (e?t?? ???? ?s? ?a??t?da?)
• S?µe?? p??sßas??
• ???t??s? ???d?? ??? ?a??t?da? (???ss???)
• ?µß???sµ?? ?f?a?µ????
• ??????S? ?SO ???O????S ? covered stent ? ßat?t?ta

47
(No Transcript)