A Carotid Case Study Using ev3 Technology
A severe right internal carotid artery (RICA) stenosis was treated successfully using the PROTÉGÉ RX Carotid Stent System and the new-generation SpiderFX Embolic Protection Device.
A 61-year-old woman was referred by her neurologist and vascular surgeon after presenting with severe progressive right carotid artery stenosis associated with a stroke affecting function in her left hand. Her comorbidities included a previous coronary bypass surgery, severe insulin-dependent diabetes, and renal failure. She had undergone left carotid endarterectomy in the remote past. A carotid duplex ultrasound demonstrated >80% RICA stenosis, and angiography confirmed a severe RICA lesion with disease extending into the distal common carotid artery as well (Figure 1A).
A 5-F JR4 catheter was used to cannulate the right common carotid artery, with advancement of a steerable .035-inch guidewire into the external carotid artery, and a 7-F Shuttle sheath (Cook Medical, Bloomington, IN) was placed in the midsegment of the common carotid artery. Again, I was able to initially cross the right internal carotid artery stenosis with my preferred wire, an .014-inch Iron Man guidewire (Abbott Vascular, Santa Clara, CA). After deployment of a 6-mm SpiderFX Embolic Protection Device, the lesion was predilated with a 4-mm X 40-mm PTA. An 8-mm to 6-mm X 40-mm PROTÉGÉ RX Carotid Stent was deployed, covering both the RICA lesion and the distal common carotid lesion entirely; postdilation was performed with a 5-mm X 40-mm PTA (Figure 1). Baroreceptor activation was treated with vasodepressors. The retrieved SpiderFX Filter was found to contain atheroembolic debris. Final intracerebral angiograms (AP/cranial and lateral) showed normal findings.
Neurologic assessment within 24 hours postintervention showed no sign of TIA or minor stroke. A carotid duplex exam will be done at the 4-week follow-up.
The retrieval of atheroembolic debris in this case highlights the importance of using embolic protection devices, and the ev3 SpiderFX Filter appeared to have several advantages over earlier devices. Most importantly, the SpiderFX Device allowed me to first easily cross the 80% stentotic lesion in the RICA with my preferred guidewire, a steerable .014-inch Iron Man guidewire. Also, the new mouth indicator (see arrow in Figure 2) and markers at the proximal and distal ends of the filter, all of which are radiopaque, give the SpiderFX filter enhanced visibility. The PROTÉGÉ RX Carotid Stent also provides great visibility with its Tantalum GPS™ Markers, which facilitated postdilation, clearly identifying the balloon's position inside the stent (white arrows in Figure 2). The visibility of both devices, combined with the ability to keep the filter low in the distal internal carotid artery without inhibiting passage of the stent delivery system fully across the internal carotid lesion, allowed me to have the filter and the end of the sheath in the field of view (even magnified views) while positioning and deploying the stent (Figure 1B). This feature may help reduce potential risks for complications related to inadvertent distal migration of the filter, which could compromise filter wall apposition and protection from emboli escaping around the filter, as well as lead to other complications.
The precision and safety with which we were able to position and deploy the ev3 PROTÉGÉ RX Carotid Stent was also aided by the EX.P.R.T. Release Technology, which minimizes jumping or premature deployment. Compared to the SpideRX System, the SpiderFX Device could be deployed and retrieved with more ease and less force because of the new hypotube connector re-design.
This case study highlights the overall ease of use of the ev3 carotid technologies and some of their unique advantages for carotid artery stenting. We believe that the ev3 carotid technologies are a great addition to our choices for carotid stenting products.
Robert L. Minor, Jr, MD, is Director of Endovascular Interventions at OSF Saint Anthony Medical Center and Director of the Rockford Cardiology Associates Research Foundation in Rockford, Illinois. All angiographic images provided by Dr. Minor. He has disclosed that he holds no financial interest in ev3. Dr. Minor may be reached at firstname.lastname@example.org.