3' Adjunctive Pharmacology

1
3. Adjunctive Pharmacology

• Dual Antiplatelet Rx
• ASA - 325
  mg bid.
• Plavix (clopidegrel) - 75 mg
  bid.
• Pre treat all patients with Atropine
• Heparin, Angiomax (Bivalirudin)
• Neo-synephrin (100ug/cc), Dopamine, NGL
• No IIB/IIIA agents

or ASA 650mg 600mg. Plavix /4hrs.Pre
Embolic / Thrombotic complications (peri and
post) are avoided with optimal
antiplatelet Rx.
2
Placing the stent delivery catheter in a safe
and expeditious fashion is the key to
successful carotid stenting .
4. Sheath placement.
3
Responses may include.
Sheath doesnt advance

• Exchange 0.038 glide for extra stiff glide or
  0.035 - 0.038 exchange wire
• Remove 5F catheter over the stiff exchange wire
  and reintroduce original dilator then advance
  sheath
• 7F sheath instead of 6F
• TERMINATE PROCEDURE!!

4
Use Sheaths not Guides

• Guiding catheters were designed to access the
  origin of vessels not be rammed into them.
• Sheaths with introducers are designed to
  atraumatically access vessels.
• For calcified more complex angulated lesions
  where more support is needed use a 7F. Sheath and
  if necessary you have the real-estate to
  support the sheath with a buddy-wire placed into
  the external carotid.

5
Remember!

• Reassess the patient selection process after the
  sheath is in place !
• Decision to proceed is made after sheath
  placemen!

5F catheter 6F
sheath
6
5. Embolic protection device

• 1. Find the best projection
• 2. Do not force the filter across the stenosis or
  tortuosity !
• - Will and does increase chance of
  an embolic event
• - Kicks out the sheath from the
  common carotid artery
• - Increases risk of spasm (isolated
  hemisphere) and dissection of the
• 
  
  distal carotid artery
• EPD will not pass
• - Stretch neck (extend head), rotate
  head reduces tortuosity
• - EPD wont easily pass Lesion
• a. Support the sheath.
• b. Pan down to make sure
  it is not going to prolaps into the arch.
• c. Leave wire tip across
  lesion.
• d. Reach for your already
  prepped bail out stuff
• Choice PT wire (Buddy wire)
• 1.5 2 mm balloon
• e. Cross and pre-dilate
  alongside EPD wire

7
Embolic protection device

• Cant place EPD with ample landing zone for
  stent !
• stop procedure!