MEET 2008 – Carotid Course Technical Aspects Why I prefer closed cells stents M. Bosiers K. Deloose P. Peeters MEET 2008 – 1 P ro c ed ura l Procedural phase • Safe stent delivery – High flexibility Wallstent – Excellent trackability – Minimal device profile MEET 2008 – 2 P ro c ed ura l Procedural phase • Optimal stent outcome – – – – Scaffolding Side branch preservation Visibility Recoil prevention 35% recoil PRE POST MEET 2008 – 3 P ro c ed ura l Procedural phase • Optimal stent outcome – Vessel conformability Open cell design with few bridges Braided stent closed cell design MEET 2008 – 4 P ro c ed ura l Procedural phase • Optimal stent outcome – Vessel conformability Open cell design with few bridges Braided stent closed cell design E V A H T H G I M E HERE W G N I S U R O F E S A AC , S T N E T S L L E C OPEN BUT… MEET 2008 – 5 CAS is no cosmetic surgery MEET 2008 – 6 CAS is all about preventing that one hit MEET 2008 – 7 P ro c ed ura l Post-procedural phase Post-procedural • The majority of strokes occur post-procedure (+/- 70%) MEET 2008 – 8 Post-procedural phase ENDOVASCULAR Æ Plaque containment! GARBAGE COMPACTOR Courtesy of M. Makaroun, University of Pittsburg / Courtesy of K. Balzer, Mulheim MEET 2008 – 9 Belgian Italian Carotid (BIC) dataset • Review 30 day CAS outcome – TIA + minor stroke + major stroke + death ALL EVENTS n/N % LATE EVENTS n/N % Total population 90/3179 2.8% 61/3179 1.9% Symptomatic population 48/1317 3.6% 36/1317 2.7% Asymptomatic population 42/1862 2.6% 25/1862 1.3% MEET 2008 – 10 “Free cell area” based analysis FREE CELL AREA <2.5 2.5-5.0 5.0-7.5 >7.5 FREE CELL AREA (mm²) Based on Houdart, Cirse 2005. MEET 2008 – 11 “Free cell area” based analysis LATE EVENTS symptomatic population Free cell area Odds Ratio 95% C.I. 2.5-5 vs <2.5 mm² 1.553 [0.197-12.261] 5-7.5 vs <2.5 mm² 4.309 [1.705-10.893] >7.5 vs <2.5 mm² 5.976 [2.733-13.065] 0 1 2 3 4 5 6 7 Odds ratio MEET 2008 – 12 “Stent design”: why closed cell? • Open cell designs in tortuous curvature PROLAPSE Courtesy of MH Wholey MEET 2008 – 13 “Stent design”: why closed cell? FISH SCALING at the concave surface of the stent Courtesy of MH Wholey Open-cell struts extending beyond the intima with focal contrast extravasation MEET 2008 – 14 “Stent design” based analysis 30-day MAE Symptomatic n/N % BIC Closed 21/934 2.2% Open 27/383 7.0% Closed 26/434 6.0% Open 13/118 11.0% CEA 37/584 SPACE Results confirmed by subanalysis SPACE-trial (Prof. Jansen) 6.3% MEET 2008 – 15 “Stent design” based analysis ALL EVENTS stent design: open vs. closed Odds Ratio 95% C.I. BIC sympt 3.297 [1.840-5.908] SPACE 1.943 [0.965-3.910] 0 1 2 3 4 5 6 7 Odds ratio MEET 2008 – 16 Future scaffolding solutions??? • Flexible porous membrane stent (+/- 100 µm ~ EPD) MEET 2008 – 17 Future scaffolding solutions??? • Flexible porous membrane stent – Membrane stent has potential for reducing the late emboli MembraX – prototype membrane stent (Abbott Vascular) Pore size 80µm Müller-Hülsbeck et al. Cardiovasc Intervent Radiol 2006;29:630-636. MEET 2008 – 18 Future scaffolding solutions??? • Flexible porous membrane stent – Membrane has minimal effect on carotid flow! In-vitro CAS SelfX Wallstent MembraX ICA distal of stent No flow separation by membrane ECA calming of flow with slight flow volume loss Greil et al. Cardiovasc Intervent Radiol 2005;28:66-76. MEET 2008 – 19 Conclusion CAROTID ARTERY STENTING ≠ cosmetic intervention = brain preservation Æ Post-operative scaffolding is most important issue MEET 2008 – 20