Understanding the of the Aortic Arch to Avoid

Understanding the of the Aortic Arch to Avoid Stroke Allan L. Brook, M. D. Director, Interventional Neuroradiology Montefiore Medical Center Associate Professor of Clinical Radiology and Neurosurgery Albert Einstein College of Medicine

DISCLOSURES Allan L. Brook, MD I have no real or apparent conflicts of interest to report.

Rationale • Arch serves as the entrance to target vessels (CAS)and to brain (CVA) • An entry port for emboli or hemodynamic compromise Aortic Arch Plaque in Stroke Sen MD

The most frequent sites of arterial and cardiac abnormalities causing ischemic stroke Albers, G. W. et al. Chest 2004; 126: 483 S-512 S

Embryology … The final configuration of the aortic arch and its branches is probably related to different growth rates in the various arteries and the associated “migration” and “merging” of the branches

Anomalous Aortic Arches “Double” “Big Mac”

Arch Configuration • Basic & most common --- 3 Branches

Imaging Modalities DSA CTA

Arch Configuration • Most common anomaly • 2 branches not 3 • So called “bovine arch” • “Dogs, cats, & rabbits” common origin of the brachiocephalic trunk and the left common carotid artery G. L. Faggioli et al. Eur J Vasc Endovasc Surg Vol 33, April 2007

Normal 3 Br Layton et al. , AJNR Am J Neuroradiol 27: 1541– 42 Aug 2006 Bovine

Arch Configuration “ 4 Vessels” • Left Vertebral direct origin • Important to recognize for entry and their implication for physiological reasons

Left Vertebral Direct Origin & Bovine Configuration * * A

Aberrant Right Subcavian Artery “Most Common of Vascular Rings” * * * A B C

Arch Elongation & Classification • Conceived to understand the increasing procedural difficulty in catheterizing arch branches • Based on the relationship of the innominate artery to the aortic arch Lin et al

Arch Types Madhwal et al. , Jour Invas Cardiolol: 20 May 01 2008 Issue Number: 5

A Real Challenge Adds Up!!! • Type 3 arch • Innominate & carotid tortuosity • Add Plaque Type 4 Increase in Complication rate

Arch Catheterization Issues • • • Anomalies Aging and elongation Calcification Plaque Stenosis Forming catheters J Emilio Exaire and Jay S Yadav

Significance of Difficult Arch Types • Challenges of variant anatomy • Curved approach • Difficult to track stiff catheters • Catheters can kink • Tendency for catheter to push out into arch Paul Myers. MD

Strategies for Difficult Access • • • Catheter choices Distal wire access Stiffer exchange wires Buddy wires Co and tri-axial systems

Simmons Not Restricted To Carotids! • Roadmapping

Arch Pathology • Plaque Important Source of Embolic Stroke Souvik Sen, MD, MS Current Cardiology Reports 2009, 11: 28– 35

Intrinsic Plaque/Clot • Iatrogenic embolization can occur as a result of aortic manipulation during invasive vascular procedures or cardiovascular surgery • Plaque morphology Ko et al. , journal of Neurology Nov 2009

Arch Pathology • Plaque Important Source of dissection • Meticulous technique can avoid emboli and dissection

Risk Factors for Embolic Complications of Aortic Plaque • Inflammation • Sheer forces of hypertension • Plaque hemorrhage from neovascularization • Aneurysm formation • Iatrogenic manipulation • Plaque imaging Magnetic Resonance in Medicine 59: 535– 546 (2008)

Stroke From Aortic Plaque • Plaques with high risk for embolization are those that are ≥ 4 mm thick • Second most prevalent embolic risk factor for stroke after atrial fibrillation • Present in 16% to 20% of all stroke and transient ischemic attack (TIA) patients Souvik Sen, MD, MS Current Cardiology Reports 2009, 11: 28– 35 Cerebrovasc Dis 2000, 10: 102– 109.

1994 • MR/DWI detects clinical and subclinical events • Increased stroke events with increase in time, manipulation and degree of arch………. .

J Korean Neurosurg Soc. 2008 September; 44(3): 159– 162

Embolic complications have also been attributed to … • The dislocation of • Air embolism atherosclerotic debris by • Effect from the cannula catheters jet of high-velocity • Thrombus formation in the flow…need for pigtail no catheter or on its surface endhole catheter • Delayed embolization • Dissection and thrombus formation

Don’t underestimate being prepared • Look at all pre-op noninvasive imaging prior to angio…

“Pearls” • The Arch is the The Doorway to the great vessels that supply the brain • Identify anatomy and anomalies • Understand pathology • Know your options • Is it safe to proceed • Avoiding trouble is better than getting out of trouble or causing a stroke!!!

Conclusion Interventional Stroke Factors Patient Physician • Anatomy • Anomalies • Pathology • Technical The procedure is then tailored to the specific anatomy with which the patient presented Peter A. Schneider, MD and Karthikeshwar Kasirajan, MD Semin Vasc Surg 20: 216 -225 2007 Elsevier Inc

Thank You!