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Refined Techniques, Good Management Can Improve Carotid Stenting Outcomes


 

HOLLYWOOD, FLA. — The safety of carotid stenting in high-risk patients is enhanced by improved stenting techniques and patient management, Dr. Jay S. Yadav said at the 19th International Symposium on Endovascular Therapy.

Improved strategies for placing carotid stents are critical, especially when treating elderly or symptomatic patients, said Dr. Yadav, cofounder and CEO of a medical device company in Atlanta and former director of endovascular services at Piedmont Hospital, also in Atlanta. He reviewed several steps to boost stenting safety.

Although access through the aortic arch poses a major stroke risk, it can be reduced with alternative access routes and better equipment. Dr. Yadav recommended an Ansel sheath and a hooked Simmons catheter to navigate through a stenotic arch. These tools can be introduced from either a brachial or femoral artery, and can reach either the left or right carotid artery.

Another tip is to be sure the embolic protection device is properly positioned—in a straight segment of the distal carotid artery. If the device is placed in a curved region, debris might slip by. In a straight segment, it's easier to fit the device snugly.

Embolic filters can also slow or arrest blood flow, especially when filters are distal to large, soft plaque. In such cases, the column of blood that's trapped proximal to the filter should be aspirated before the filter is collapsed and withdrawn. If such stagnant blood isn't removed, trapped particles can embolize on withdrawal, Dr. Yadav said.

Another tip is to minimize filter deployment duration. Once an embolic protection device is deployed, stenting should start and finish within 5 minutes. In a recent study, patients with a filter in place for more than 20 minutes had double the risk of stroke, versus patients with shorter dwell times.

In certain highly challenging cases with very stenotic vessels, deployment of two distal protection devices can help ensure that all embolic material is trapped.

Proper management can also improve outcomes. Dr. Yadav suggested starting treatment with clopidogrel a week before the stenting procedure, rather than relying on a loading bolus.

During the procedure, patients should receive heparin or bivalirudin, with a target activated clotting time of 275–300 seconds. After stenting, patients should receive clopidogrel and aspirin for 3–4 weeks.

Start treatment with clopidogrel a week before the stenting procedure, rather than relying on a loading bolus. DR. YADAV

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