Fill a 20- or 30-ml luer lock syringe with diluted contrast medium (2/3:1/3 concentration).

Attach the syringe to inflation device using a three-way stopcock and aspirate the contrast medium into the inflation device leaving 2–3 ml in the syringe.

Ensure that the entire inflation system is free of air bubbles.

Attach the system to the balloon inflation port of the delivery system.

Turn the stopcock so that the inflator is occluded and there is direct communication between syringe and balloon catheter.

Aspirate to remove air from the system, holding the syringe upright. Gently allow the plunger to return toward its original position so that air is replaced by contrast in the stent system.

Repeat the process, until air bubbles are no longer visible during aspiration.

Allow the ambient pressure to return to the balloon before detaching the syringe.

A meniscus will appear in the balloon inflation port when the syringe is detached.

Purge the aspirated air from the inflation system by inverting the syringe and injecting out the air.

If air bubbles continue to be aspirated despite multiple aspirations, discard the system and prepare another.

We usually perform an in vivo preparation, which is described below in the sequence it is undertaken during procedure.

Moisten the stent system by soaking it in a bowl containing heparinized saline (DO NOT wipe down with moist gauze sponge as the stent graft may be disrupted by gauze fibers).

Visually confirm that the stent graft is located between the proximal and distal stent markers.

Place a 0.014″ microguidewire into the lumen of the balloon catheter.

Ensure the appropriately positioned guide catheter (distal tip of the guide catheter should be proximal to the lesion) is stable.

Advance this system through the RHV of the guide catheter.

Using fluoroscopy and roadmapping, advance the delivery system to the target lesion and position it optimally such that the distal radiopaque marker on the balloon catheter should be distal to the lesion and the proximal marker, proximal to the lesion.

Ensure that the distal marker is at least 1 mm distal to the lesion.

Once optimal positioning is confirmed sufficiently tighten the RHV around the system. Do not over tighten, which may impede the proper functioning of the delivery system.

If ex vivo balloon preparation was performed, then securely attach the inflation system to the balloon inflation port by making a wet meniscus to meniscus connection. To do this, fill the port with diluted contrast to replace any air, and then make a meniscus to meniscus connection with the inflation device.

Ensure that inadvertent, premature deployment of the balloon catheter does not occur during attachment.

If ex vivo preparation was not performed, then do in vivo preparation as follows:

Prior to stent deployment, confirm that the stent is appropriately positioned and the guide catheter and balloon catheter are free of slack.

Turn the stopcock so that it is off to the syringe and open to inflation device and balloon catheter port.

Place the compliance chart in front of you.

Turn the inflator slowly (approximately 1 atm per 15 s) to gradually inflate the balloon. Inflate to a minimum of 14 atm to expand the stent by balloon inflation.

Use the compliance chart to achieve the appropriate inflation pressure for a particular stent size.

Do not exceed the rated burst pressure or expand the stent beyond its actual size.

Maintain the inflation pressure for 15–30 s for full expansion and adequate approximation of the stent to vessel wall. Underexpansion may result in stent graft movement or lack of proper coverage of perforation.

After completion of stent deployment, deflate the balloon completely by applying negative pressure, if needed. Wait at least 15 s to ensure complete deflation.

Confirm fluoroscopically that the balloon is completely deflated.

Fully open the RHV of the guide catheter.

Maintaining negative pressure, withdraw the balloon catheter from the deployed stent. Ensure that the guidewire and guide catheter maintain their position.

Close the RHV around the guidewire, once the balloon catheter is removed.

Perform angiography to confirm complete apposition of stent against vessel wall.

If complete apposition was not achieved, then use a non-compliant, high-pressure balloon of the same size (or slightly larger) and length as the balloon of the delivery system to perform a second stent expansion.

Do not overdilate the vessel to the extent that dissection may occur.

The final post-procedure angiogram should demonstrate the stent diameter to be the same as (or slightly larger) than the vessel proximal and distal to the stent.

Observe the patient (especially if procedure done under moderate sedation) and perform periodic angiographic assessment within the initial 30 min after stent deployment.

Perform post-procedure cerebral angiography to rule out any embolic complication.

Do not perform MRI for approximately 8 weeks (until the stent has completely endothelialized), to avoid the risk of stent movement.

If anticoagulant and/or antiplatelet therapy is contraindicated.

Severe vascular tortuosity or anatomy that would preclude the safe introduction or maintenance of a guide catheter, sheath, or interventional devices.

Hypersensitivity to nickel-titanium.

Uncorrected bleeding disorders.

Lesions in the ostium of CCA.

Verify lab values including platelet count, BUN, CR, APTT, PT/INR, and ß-HCG for females of reproductive age group.

In case of renal insufficiency, diabetes, CHF, etc., ensure usage of diluted non-ionic contrast agent and carefully pre-plan to maintain contrast load to minimum.

If unable to administer Plavix in a timely fashion, another option is:

Abciximab (Rheopro^®) in a L.D. of 0.25 mg/kg followed by continuous IV infusion of 0.125 µg/kg/min (to a maximum of 10 µg/kg/min) for 12 h, then d/c. Start this after arterial access has been secured. Administer Plavix 75 mg PO the same evening and then 75 mg PO daily.

ASA 81–325 mg PO daily.

Liquids only on morning of procedure.

NPO (for ≈6 h) when procedure performed under GA.

Obtain informed consent for angiography, angioplasty, and stenting.

Ensure two IV lines inserted.

Insert Foley. Patient will be more comfortable and cooperative with an empty bladder in case the procedure becomes prolonged.

Position patient on neuroangiography.

Attach patient to pulse oximetry and ECG leads for monitoring O2 saturation, HR, cardiac rhythm respiratory rate, and BP.

0.9% NS + 20 meq KCl @ 75 cc/h (adjust to higher rate as needed).

Fentanyl 25–100 µg IV prn.

Versed 0.5–1 mg IV prn.

Heparin IV per physician instructions. (See “Technique” below.)

Micropuncture kit 4 Fr.

6-Fr short sheath (10 cm); use long sheath if tortuous vasculature, e.g., a 6-Fr shuttle sheath which may be advanced initially over dilator into the descending aorta and then into common carotid over 6-Fr H1 slip catheter. A shuttle sheath is also preferable because it will provide greater support and significantly decrease the likelihood of the apparatus collapsing into the aortic arch at critical time points, e.g., during stent deployment.

6-Fr H1 slip catheter.

Rotating hemostatic valves (2). Ensure the RHV attached to the Guide catheter is ≥0.096″ or 2.44 mm.

Pediatric transducers (30 ml/h; 2).

Guide catheter: 6-Fr Envoy^® MPC guide catheter (90 cm).

Diagnostic catheter: Terumo^® front-angled glidecath 5 Fr (for diagnostics. May use Envoy guide catheter for the same purpose).

Front-angled glidewire (0.035; Terumo).

Embolic protection system (Guidant, Accunet). The package containing this product has three pouches which contain the following: RX Accunet™ delivery system comprising of 0.014″ guidewire with filter basket, peel away delivery sheath, introducer tool, torque device with peel away adapter, and flushing tool.

The other two pouches contain filter basket recovery catheters. One has a shapeable tip, while the other is low profile and more flexible.

Selection of filter basket size will depend upon the diameter of carotid artery. (See chart in “Technique” section.)

Balloon dilatation catheter: Aviator™ Plus (RX) (Cordis, Warren, NJ, USA).

It is a rapid exchange (RX) catheter.

It is available in 4–7 mm balloon diameter range. Select the appropriate size for the vessel being treated, based on the table provided with the product.

Carotid stent: Acculink™ (Guidant). See tables in “Procedure” section for selecting the appropriate size to the vessel being treated, in untapered or tapered stents.

Syringes 10 cc (at least 3), 20 cc (at least 4), 3 cc (for ACT and angioplasty balloon preparation).

Three-way stopcock: 3.

Torque device.

Telfa strip.

Mandrel for shaping microwire tip.

Angioseal™ closure device (6 Fr). Use larger size if a larger sheath inserted.

Attach a 6-Fr shuttle sheath to a continuously running flush of heparinized saline and confirm that the system is free of air bubbles.

Insert the provided dilator into the shuttle sheath.

Gain access with micropuncture needle using modified Seldinger technique.

Insert a glidewire into the descending aorta.

Remove the 4-Fr sheath over the wire, maintaining wire access to the vasculature.

Introduce the shuttle sheath-dilator assembly onto the glidewire.

Using fluoroscopy, advance the shuttle sheath into the aortic arch, ensuring that the tip of the glidewire is always leading.

Retract and remove the dilator.

Administer 5000 IU heparin IV. Remember to perform ACT approximately 20–30 min later. Using a 15-cc syringe, draw 10–15 cc of blood from the sheath and then immediately attach a 3-cc syringe to draw 1–2 cc of blood, which is sent for ACT.

May return the blood drawn prior to ACT sample back to the patient via the sheath, as long as the distal tip of the sheath is proximal to the carotid vasculature.

Check ACT hourly throughout the procedure and administer heparin IV to maintain an ACT of 300–350.

Attach a 6-Fr H1 slip catheter to a continuously running flush of heparinized saline and confirm that the system is free of air bubbles.

Advance the slip catheter over the guidewire into the sheath if an exchange length wire has been used. Ensure that the distal tip of glidewire remains in its position.

If the guidewire is not exchange length, remove the wire from the shuttle sheath, introduce it into the H1 catheter, and then advance this system into the sheath.

Using fluoroscopy, continue to advance the slip catheter until it emerges from the distal tip of the shuttle sheath.

Ensure that during navigation the glidewire is in the lead.

Navigate the glidewire into the common carotid artery (CCA) and advance the slip catheter over it.

Use roadmapping, as necessary.

Ensure that the manipulation remains proximal to the stenosed segment.

If greater wire purchase is needed, advance the glidewire into the external carotid artery not internal carotid artery (ICA).

Once the slip catheter is in the proximal CCA, advance the shuttle sheath over the slip catheter and glidewire.

After the shuttle sheath is positioned in the CCA, retract and remove the glidewire and slip catheter from the shuttle sheath.