The evolution of stent design related to carotid stenting strategy

A. Cremonesi*, F. Castriota*

(*) Interventional Cardio-Angiology Unit Villa Maria Cecilia Hospital Cotignola (RA) - Italy

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Carotid protected procedure

Definition

Are anatomy and/or carotid plaque features influencing indication and technical CC engagement aspect of CAS? selection EPD
Stent selection & implantation & management

Highly calcified plaque + tortuosity

Strategy endpoints
1. 2. 3.

Plaque remodelling before stent implantation Long acting high radial force stent Respect of original anatomy

Type of EPD Pre-dilation Type of carotid stent

Distal filter Cutting balloon Nitinol, open cell geometry

Sub-occlusive soft lesion

- Type III aortic arch -

Strategy endpoints
1. 2.

Management of massive distal embolization Prevention of plaque prolapse (late events)

Type of EPD Type of carotid stent Proximal occlusion Braided mesh structure

Do we need evolution in stent design?

Self-expanding stent technical features

Foreshortening Conformability or flexibility Vessel wall adaptability Scaffolding & wall coverage Radial strength Radial stiffness

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Carotid Stenting Strategies

Perfect

A D C
A: Braided mesh

B: Laser cut tube, closed cell design C: Segmented crown, open cell design D: Flat rolled sheet, closed cell design

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Analysis on 377 consecutive patients

A. Cremonesi et al. EuroIntervention, December 2005

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1. 2.

Late embolic events: dynamics

Late embolic events occur in the post-procedure period, between stent implantation and its complete re-endotelization (3-4 weeks). Late symptomatic embolic events depend mostly on prolapsed soft tissue as well as platelet micro-aggregates / thrombi detached from the stent metallic frame

Our main future task must be to improve:

Carotid plaque characterization, to tailor both the indication and the endovascular procedure Stent performances, to promote a real material biocompatibility and specific intrinsic anti-embolic properties, therefore protecting patients and not only procedures

Scaffolding and wall coverage

Scaffolding:

Wall coverage:

amount of support a ratio between quantity of Plaque stent gives to the vessel covering material in stent wall at the lesion siteacting plaque comparison to amount of Long vessel tissue

prolapse prevention

More scaffolding

More wall coverage

Closed cell geometry stent

Less plaque prolapse

High grade soft ulcerated lesion

- Type I/II aortic arch, RCCA occluded -

Strategy endpoints
1. 2.

Prevention of massive distal embolization Prevention of plaque prolapse (late events)

Type of EPD Type of carotid stent Filter wire + proximal occlusion Braided mesh

High grade soft ulcerated lesion

- Type I/II aortic arch, RCCA occluded -

MO.MA: ECA stop flow blockage

ECA stop flow blockage EPI EZ filter-wire in ICA

CCA+ECA stop flow blockage EPI EZ filter-wire in ICA Carotid Wallstent 9/30 mm

High grade soft ulcerated lesion

- Type I/II aortic arch, RCCA occluded -

ing e er qu ov la on e c g p nti qu tin ve Pla ac pre ng pse Lo la ro p

Total occlusion time 72 seconds

2005: Evolution in Carotid Artery Stenting

NexStent

From a flat Nitinol sheet

to a rolled stent without sealing joints

Dynamic Tapering Concept

Cylindrical Stent

Nexstent
Dynamic Tapering

Tapered Stent

Size dynamic 4-9 mm

Morpho dynamic

Radial strength
Tapered by design Self Tapered

Static Tapering

Anatomic conformability

The Next Era in Carotid Artery Stenting

NexStent
Clinical efficacy

CABERNET Trial

450 patients enrolled 30-day composite end-point (death, stroke, MI): 3.8%

NexStent drawbaks

Need of stent evolution in the clinical practice

Incidence of risky carotid plaques in the endovascular daily work:

Echolucent

plaques Plaque erosion / ulceration Vulnerable plaque

Establish the need of new generation stents with intrinsic anti-embolic properties

Carotid angioplasty and stenting: lesion related treatment strategies

A.Cremonesi, F.Castriota, C. Setacci et al .EuroIntervention Dec. 2005
Clinical data and angiographic evaluation
Population study Male Female Age Carotid de-novo lesion Carotid post-endarterectomy restenosis Carotid post-PTA/stenting restenosis No. 377 264 113 71 345 32 1 No. Right carotid artery Left carotid artery Diameter stenosis % Lesion length mm Bilateral carotid disease >70% Contralateral carotid occlusion 201 176 81 18 118 43 % 100,00 70,03 29,97 S.D. 8,4 91,51 8,49 0,27 % 53,32 46,68 S.D. 6 S.D. 9 31,30 11,41

Angiographic evaluation:

Neurological history Plaque characteristics

ing Symptomatic Patients ct244 g a ion Asymptomatic Patients lon ent 133 nd rev itNo. Echo plaque characteristics g a r y in se p ajo 78 r Uniformly echolucent s m ve lap echolucent ase86 Predominantly co pro the c 97 ue ue Predominantly echogenic in cted q q Uniformly Pla pla eded seleechogenic 116 No. Echo plaque complexity ne f un 52 o Severe calcifications
Neurological history
No. Erosion / Ulcer 134 % 64,72 35,28 % 20,69 22,81 25,73 30,77 % 13,79 35,54

Self-expandable stent inventory

Self expandable stents: 385

ing ts ct eNo. n a Carotid Wallstent - Boston Scientific st 197 ng n o o Acculinkl- Guidant 133 d nti an Xacte Abbott 27 g rev - % rin p - Medtronic es 17 e Exponent 8,08 s ov pse Proteg - ca c la 9 n 5 ed ev3 e o i t qu pr sedConformex - Bard 1 la e ec u Smartel P qu 1 ns Precise - Cordis a pl fu o

% 51,17 34,55 7,01 4,42 2,34 0,26 0,26

Do we need carotid stent evolution?

Conclusion

The ideal stent design doesnt exist at the moment. The carotid lesion characteristics Material and devices evolution should be always the reference point should be driven always for a rational decision making. by treatment strategy needs Late embolic events are still now an unsolved problem: stent scaffolding might be the right solution.