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How to Overcome Difficulties with Tortuous Arterial AnatomyEuropean Society of Neuroradiology (ESNR)
Module 1 (Ischemic Stroke) – April 30th, 2019
Barcelona, Spain
Adnan H. Siddiqui, MD, PhDProfessor & Vice-Chairman, Department of Neurosurgery, University at BuffaloDirector Neurosurgical Stroke Service, Kaleida HealthChief Medical Officer, Jacobs Institute
DisclosuresCurrent Research Grants: Co-investigator: NIH/NINDS 1R01NS091075 Virtual Intervention of Intracranial
Aneurysms
Financial Interest: Amnis Therapeutics, BlinkTBI, Inc, Buffalo Technology Partners, Inc., Cardinal Consultants, LLC, Cerebrotech Medical Systems, Inc, Cognition Medical, Endostream Medical, Ltd, Imperative Care, International Medical Distribution Partners, Neurovascular Diagnostics, Inc., Q’ApelMedical, Inc., Rebound Therapeutics Corp., Rist Neurovascular, Inc., Serenity Medical, Inc., Silk Road Medical, Spinnaker Medical, Inc., StimMed, Synchron, Three Rivers Medical, Inc., Viseon Spine, Inc.
Consultant/Advisory Board: Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA, Inc., Cerebrotech Medical Systems, Inc., Cerenovus, Corindus, Inc., Endostream Medical, Ltd, Guidepoint Global Consulting, Imperative Care, Integra, Medtronic, MicroVention, Northwest University – DSMB Chair for HEAT Trial, Penumbra, Q’Apel Medical, Inc., Rapid Medical, Rebound Therapeutics Corp., Serenity Medical, Inc., Silk Road Medical, StimMed, Stryker, Three Rivers Medical, Inc., VasSol, W.L. Gore & Associates
National PI/Steering Committees: Cerenovus LARGE Trial and ARISE II Trial; Medtronic SWIFT PRIME and SWIFT DIRECT Trials; MicroVention FRED Trial & CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial;
No consulting salary arrangements. All consulting is per project and/or per hour.
• Tortuosity• Fixed Immovable Vessels Vessel
Fragility• Distance
Access Difficulty Intracranial AccessIt’s a long way up
Many kinks and curves along the way
‘Corkscrew’ in boneFragile vesselsSuspended in H2O
The Brain is NOT!!
Endovascular Techniques
Most Organs are Fairly Forgiving
90 to >180° loopsBony canal
Intracranial Access
Guide catheters–CCA 5-10 Fr–Cervical ICA 4-6 Fr–Petrous ICA 4-6 FrGuide catheter problems–Column strength–Stability in vessel–Prolapse into arch
Intracranial AccessAccessAortic Arch Angles
cccccecessss
Intracranial Access
Intracranial
Skull base
cervical
M22 1.3.3-3-2mmM2M1
211 2
122-
mm2m2..33122---3mmM1
A12M11 22
111 1.52.55-
mmmm3m355---2.5mm
Supraclinoid ICAA 2.5.5-5-4mmSupraclinoid ICACavernous ICA
CAAA 3CAA
333-55 mm4m4.2.A 2A
33--4.5mmCavernous ICAPetrous ICA
ICAAA 3
CA33-
3 5m4.433AA 3CA33--5mm
ICAA 3.5.5-5-6mm
ECAA 2.5.5-5-4mm
CCAA 66-6-10mm
90
120 11011011090
9018080Coatings are essentialPushabilityFlexibilityAtraumatic
Intracranial Access
CoatingsCatheters / Stents
Lubricity (Access)AntithromboticsRestenosis
What is a ‘tough’ aortic arch?Type III archBovine archAcute angulation of L CCA origin (< 50 degrees)Aberrant R SCA with common bilateral CCA trunkHeavy burden of arch atherosclerosisExtreme tortuosity of great vessels–>= 2 turns measuring <= 90 degrees
Arch Study
It is essential that the aortic arch be evaluated prior to the undertaking of an endovascular procedure:
CTAMRAAortic Arch Angiography
Age-related Changes of the Aortic Arch-Arch elongation-Lengthening supraaortic arteries-Atherosclerosis-Calcified-Less compliant
Primary Driver:HTN
Vascular tortuosity resulted in aborting the endovascular procedure in 4% - 6% of cases
Occurrence of periop complications increased in patients with unfavorable arch anatomy, but NOT in
patients >= 80 yrs
Guide Catheter Stability
When combined with a stiffened, atherosclerotic vessels, the geometry of a type III arch is contrary to the forces needed to maintain guide catheter stability.
Carotid-Aortic AngleLine from the apex of the aortic arch to the target vessel, then through the first major curve
This produces a surrogate marker for the geometric change which occurs during vessel aging
0
10
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1 2 3 4 5
Over 80Neuro complication
Over 80Non - Neuro complication
Over 80Nocomplication
Under 80
Deg
rees
Points to Consider:1. Elderly patients should have their aortic arches imaged prior to
stroke intervention2. Patients with angles less than ~50 degrees may be at increased
risk for neurologic complication
Examples of Difficult Arch Access
Type I – “Bovine Arch” Type III – “Bovine Arch” Tortous Access
Type III arches access strategy: Engaging the artery with a Vitek or Simmons catheter and using a stiff 0.035” wire as a rail.
When do I need which catheter configuration?
Use of the Vitek Catheter for difficult arch catheterization
Vitek Catheter is used in similar fashion as Simmons-II,
but without the need for reconstitution
Another option when dealing with difficult arch: Use of the 8 Fr Simmons-2 catheter for catheterization difficult arch:.
A stiff wire is advanced into the axillary artery to gain distal purchase.
B: The catheter is advanced into the distal subclavian artery over the stiff wire.
C: The wire is removed, the catheter is slowly pulled back until the preshaped “knee” segment reaches the junction of the subclavian artery and aortic arch
D: Pushing the reconstituted catheter will now move the catheter further proximally
into the aortic arch.
E: Once the Simmons-2 catheter has been pushed so that its tip is proximal to the origin of the vessel of interest (in this case, the innominate artery), it is then pulled back, “hooking” into and thus migrating within the target vessel.
Gentle traction will ensure the catheter knee remains at the juncture of the target vessel and the aorta, with the distal portion of the catheter firmly anchored within the target vessel.
3 x .014in guidewiresPrevents ‘kickback’ force
Bailout OptionsAlternative access point (radial/brachial – more helpful for vertebral than carotid access)Direct carotid puncture or open cut-downCEA instead of CAS despite high risk
SummaryPay attention to arch anatomy during planning of interventionOlder patients with type III arches remain a challengeThink of different catheters and strategies to overcome access challenges
Fortune favors the prepared mind- Louis Pasteur
For proper planning, it is essential to have a pre-operative CTA of the head & neck that iincludes the aortic archPre-operative factors affecting device setup
and access choice–Anatomical Factors
• Arch type, location of occlusion, tandem lesions–Non-Anatomical Factors
• Anticoagulation/tPA lower rate of access complications with radial access• Body habitus morbid obesity may preclude femoral access
Access for acute ischemic stroke
Femoral Radial Brachial Direct Carotid
Femoral AccessAAdvantagesFamiliarAllows for larger catheters–i.e. balloon guidesGreater freedom to
improviseAnatomic–Left vertebral artery–Type I & II arches
DisadvantagesHigher rate of access site
complicationsMore severe access site
complications than radial–i.e. retroperitoneal hematomaAnatomic–Right vertebral artery–Type III arches–Bovine arches
Radial AccessAAdvantagesLower access site
complicationsAnatomic–Right vertebral artery–Bovine arch–Type II & III arches
DisadvantagesLess familiarLimited sheath size (6
French)Anatomic–Left vertebral artery–Tortuous Left carotid (increased length)–Aberrant anatomy
Radial Access
Retrospective case-control study51 patients–18 (35%) transradial, 33 (65%) transfemoralOutcomes–No significant difference in time to reperfusion, successful revascularization (TICI 2b), or discharge mRS
J Neurointerv Surg. 2019 Jan 22. pii: neurintsurg-2018-014485.
Brachial AccessTypically used for cases in which femoral access is not
technically possible (e.g. severe PAD) and there is a need for larger than 6F access
AAdvantagesAllows for larger cathetersGreater freedom to
improvise vs. radialShorter access distance for
left carotid or left vertebral artery access
DisadvantagesNot familiarRequires manual pressure
for arteriotomy closureRisk of median nerve palsy
Direct Carotid AccessTypically used as a last ditch effort in which other routes
have failed or are technically not feasibleTwo methods–Percutaneous–Surgical cut down
AddvantagesBypass tortuous or
occluded anatomy
DisadvantagesNot familiarPercutaneous method typically
requires manual pressure for arteriotomy closurePotential complications–Cervical hematoma, cervical ICA dissection/pseudoaneurysm
Case Example: Direct carotid accessPercutaneous methodInjection through microdilator
Case Example: Direct carotid accessPercutaneous methodInjection through micro-dilatorPlacement of 6F sheathDevice Setup–0.035 glide wire–5MAX ACE–Synchro 2 microwire–Velocity microcatheter–StarClose (percutaneous closure)
Case Example: Direct carotid accessSingle pass ADAPTTICI 3 (time to recan 25min)
Case Example: Direct carotid accessFailure of StarClosePost-op neck hematoma w/ notable
tracheal deviationDischarged to subacute rehab on
POD#16–Significant improvement in left lower extremity strength–Persistent LUE dense paresis
CASE 2
85 year-old male who woke up with NIHSS of 9
Right MCA bifurcation cut offRight gaze preferenceLeft UE and LE driftLeft sensory extinctionDrowsy, dysarthricLeft facial droop
CT perfusion: superior MCA perfusion deficit with preserved volume
Type III arch with a significant turn in the proximal brachiocephalic
Direct carotid stick
Ultrasound guided micro puncture to avoid IJVMicrodilator, roadmap6F sheath
Right superior MCA cut off 5MAX ACE, Velocity, Synchro 2Micro run through velocity after crossing clot
5 MAX
Velocity
Solitaire deployed and retrieved with suction through the ACE- TICI 3 revas
Solitaire
Post operative course20 minute hand pressure after sheath removalExtubated in 2 hoursNIHSS 2- minimal sensory extinctionFacial droop, gaze preference and motor deficits recovered completely
General Concept: Match select catheter with aortic arch anatomy, based on approach
Select catheters are designed with different configurations to improve access–Use this to your advantage
Congenital aortic arch variants
Left-Sided Right-Sided Double
Left-sided aortic arch variants Left-sided aortic arch variantsBBovine ArchPrevalence: 9%Considerations–Access to the left common carotid may be easier from the right radial artery–For the left common carotid artery, if utilizing a femoral approach, then a Simmons select catheter is recommended; specifically in the alpha configuration
Left-sided aortic arch variantsBBovine-Type ArchPrevalence: 13%Considerations–All major vessels are accessible from either femoral or radial approach–For the left common carotid artery, if utilizing a femoral approach, then a Simmons or VTK select catheter is recommended
Left-sided aortic arch variantsDDiverticulum of KommerellDorsal arch remnantBelieved to arise from a persistent right 6th
pharyngeal archPrevalence: < 0.5% Considerations–Likely a contraindication for right radial access (except for right vertebral artery)
Left-sided aortic arch variantsAAberrant Right SubclavianAssociated with aortic coarctation, PDA, VSDPrevalence: 0.5 - 2% Considerations–Likely a contraindication for right radial access (except for right vertebral artery)
Right-sided aortic arch variants
Right-sided aortic arch variantsMMirror Image BranchingResults from interruption of the left pharyngeal
arch during developmentAssociated with congenital heart disease (e.g.
tetralogy of Fallot, truncus arteriosus, etc.) in 98% of casesPrevalence: 0.05-0.1%Considerations–All major vessels are accessible from either femoral or radial approach–May have difficulty reconstituting the select catheter from a radial approach
Right-sided aortic arch variantsAAberrant Left Subclavian ArteryResults from regression of the left arch between
the left CCA and subclavian arteryPrevalence: 0.025 – 0.5%Considerations–All major vessels are accessible from either femoral or radial approach–Consider left radial access for left vertebral artery
Right-sided aortic arch variantsIIsolated Left Subclavian ArteryLeft subclavian branches off the left pulmonary
artery through the left ductus arteriosusPrevalence: < 0.05%Considerations–Left vertebral artery is only accessible vial left radial access
Acquired aortic arch variants
Acquired aortic arch variantsThese changes are acquired through age related
changes–Arch elongation–Lengthening of the supraaortic arteries–Atherosclerosis–Calcified–Decreased compliancePrimary driver of these changes is hypertension
Acquired aortic arch variantsTType I ArchTechnical: Right brachiocephalic artery is less
than 1 CCA diameter below the top of the archSimplified: Right brachiocephalic artery is in-line
with the left subclavianConsiderations–All major vessels are accessible from either femoral or radial approach–If femoral approach, recommend angled or VTK select catheter
Acquired aortic arch variantsTType II ArchTechnical: Right brachiocephalic artery is
between 1 & 2x the CCA diameter below the top of the archSimplified: Right brachiocephalic artery is below
the left subclavian but above the aortic notchConsiderations–All major vessels are accessible from either femoral or radial approach–If femoral approach, recommend VTK select catheter
Acquired aortic arch variantsTType III ArchTechnical: Right brachiocephalic artery is greater
than 2x the CCA diameter below the top of the archSimplified: Right brachiocephalic artery is below
the aortic notchConsiderations–Right common carotid artery
• May be more accessible from radial approach• If accessing from femoral approach, recommend Simmons select catheter
–If femoral approach for left vertebral artery or left common carotid, recommend VTK select catheter
Carotid TortuosityTTortuosity Index (TI)The sum of all angles diverging from the ideal straight
axis of the common carotid, considering a 90 degrees ideal angle for the origin from the archDeveloped as a predictive measure of technical failure
for carotid stenting –TI > 150o associated with 3x rate of technical failure
Carotid TortuosityCCarotid-Aortic AngleLine from the apex of the aortic arch to
the target vessel, then through the first major curveThis produces a surrogate marker for the
geometric change which occurs during vessel aging
Carotid TortuosityCCarotid-Aortic AnglePatients over 80 years old with angles
less than 50 degrees are at an increased risk for neurologic complication
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10
20
30
40
50
60
70
80
90
100
110
120
130
1 2 3 4 5
Over 80Neuro complication
Over 80Non - Neuro complication
Over 80Nocomplication
Under 80
Deg
rees
Management of carotid tortuosityConsider starting by obtaining access with a diagnostic
catheter (more flexible), then exchanging a stiff exchange wire to climb the intermediate catheter and guide–Terumo Glidewire Advantage (014, 018, or 035)–Boston Scientific V-18 ControlWire
Specific Techniques: Tower of PowerMultiple parallel guide wiresConsecutively passing 3 smaller-
diameter microwires together in parallel to secure and support wire accessThe 3 smaller wires create a stable
construct in which a distal wire allows passage of a diagnostic catheter or guide catheter–Decreases the “kickback” forceCommercial devices also available (e.g.
ZigiWire)
Specific Techniques: 8F Simmons-2 catheter
Specific Techniques: 8F Simmons-2 catheter
A. A stiff wire is advanced into the axillary artery to gain distal purchase. B. The catheter is advanced into the distal subclavian artery over the stiff wire. C. The wire is removed, the catheter is slowly pulled back until the preshaped
“knee” segment reaches the junction of the subclavian artery and aortic arch
Specific Techniques: 8F Simmons-2 catheter
D. Pushing the reconstituted catheter will now move the catheter further proximally into the aortic arch
E. Once cstheter tip is proximal to the origin of the vessel of interest (in this case, the innominate artery), it is then pulled back, “hooking” into and thus migrating within the target vessel.
F. Gentle traction will ensure the catheter knee remains at the juncture of the target vessel and the aorta, with the distal portion of the catheter firmly anchored within the target vessel.
Specific Techniques: MIVI Q for thrombectomyQQ Distal Access Catheter (MIVI Neuroscience)–Available in 3F, 4F, 5F, & 6F“Aspiration catheter on a stick”–Inserted within a 8F guide catheter (e.g. PneumbraNeuron MAX 088)–Aspiration is performed from the guide catheter, therefore allows for a biaxial aspiration thrombectomy setup (ADAPT or Solumbra)Catheter design is very flexible, smaller sizes (3F & 4F)
are exceedingly useful for distal thrombectomies and tortuous anatomy
Case Example: MIVI for distal thrombectomy70 yoM w/ Afib, off anticoagulation, presenting with NIHSS 10 (Aphasia, R facial, R homonymous, R sensory, and L gaze)
Page: 11 of 19Page: 11 of 19 IM: 37IM: 37Page:18of 26Page:18of 26 IM:63IM:63
Case Example: MIVI for distal thrombectomyAccess8 Fr SheathNeuronMax 088 (Pneumbra)VTK select catheter
(Pneumbra)038 exchange length
glidewireMicrosystemMIVI Q 3F Distal Access
CatheterSynchro2 microwire
Case Example: MIVI for distal thrombectomyDelayed filling with distal M3 occlusion
Case Example: MIVI for distal thrombectomyAspiration with MIVI Q 3F
Page: 168 of 286Page: 168 of 286 IM: 620009IM: 620009 cm* cm*
Page: 155 of 286Page: 155 of 286 IM: 610009IM: 610009 cm* cm*
Case Example: MIVI for distal thrombectomyTICI IIb Recanalization (post-op NIHSS 7)
Pre-Aspiration Post-Aspiration
Case Example #2: MIVI for thrombectomy
75 year-old female presenting with acute aphasia and right hemiparesisUnknown last known normal–Not a candidate for tPAExam (NIH stroke scale 23)–Awake, non-verbal, with left gaze preference and right facial droop–Dense right hemiparesisPast medical history–Cholangiocarcinoma, COPD, CHF, & DVT/PE (on apixaban)
CTA & CT PerfusionLeft ICA terminus occlusionPartial area of core infarct on perfusionASPECTS: 6
CBV TTP
Device Setup8F right common femoral sheathAccess–Neuron Max 088 (Pneumbra) guide catheter–5F Sim Select catheter (Pneumbra)–035 andgled Glidewire (Terumo)Aspiration–MIVI Q 6F (MIVI Neuoscience) distal access catheter
Velocity (Pneumbra) microcatheterSynchro 2 (Stryker) microwire
–MIVI Q 4F (MIVI Neuroscience) distal access catheterVelocity (Pneumbra) microcatheterChikai black 18 (Asahi) microwire
TICI 2b Recanalization
Post-op Imaging
Subtle contrast stating Left MCA and scattered bilateral embolic strokes
Post-op courseExam improved to NIH stroke scale 10–Alert with moderate expressive, following simple motor commands–Strength: R upper extremity 3/5; Right lower extremity 2/5Found to have mobile tricuspid vegetation and gram negative bacteremia
(Klebsiella oxytoca)–Started on ceftriaxoneDischarged to medical rehab unit on POD#10
Interactive Case
Background88 year-old female on apixaban for atrial fibrillation with history of right MCA stroke with no residual deficit, presenting with right facial droop and aphasiaNIH stroke scale 17High function, independent at home (mRS 1)Last known normal 2 hours prior to arrivalNo tPA due to apixaban
ImagingCT head ASPECTS 10 w/ remote right MCA infarctCTA with distal left M1 occlusionCT perfusion with no evidence of core infarct
Which approach would you use?Considerations regarding arterial accessOn anti-coagulationBovine archProximal left CCA and distal ICA tortuosity
Our decision: right radial
Device SetupAccess6F right radial sheath6F Benchmark 071 guide catheter, 105cm (Pneumbra)5F Sim Select catheter (Pneumbra)038 exchange Glidewire (Terumo)
Aspiration5F Sophia intermediate catheter, 125cm (Terumo)Velocity microcatheter (Pneumbra)Synchro2 Microwire (Stryker)Embotrap stent-retriever, 5mm x 3mm (Cerenovus)
TICI 2b recanalization after 1st pass (Solumbra) Further considerations2nd pass mechanical thrombectomyIntra-arterial tPAIV heparin infusion
What would you do?
Our PlanIA tPA administered into the left M2–10 mg tPA diluted into 20cc saline syringe–Attach 20cc syringe and 3cc syringe to a 3-way stopcock attached to the microcatheter–tPA administered in 2mg aliquots each followed by a microinjection–Stopped after 4mg due to increased resistance within the catheter
Final Run: TICI 2b
Post-OpPost-operative ICHSlight improvement in post-op exam
NIHSS 12Suffered recurrent embolic stroke on
POD#3–NIHSS increased to 25Family elected to transition to comfort
care on POD#8
Descussion PointsAccess decision–Radial access worked very well to cross the Bovine arch–No access site complicationShould we have stopped with TICI 2b after 1 pass?–When is TICI 2b sufficient?–When is TICI 2b not sufficient?
Thank You
