logging in or signing up Carotid artery stenting endovascular course March 04 MOHAMEDOMAR Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 355 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: August 28, 2010 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... By: manuheart123 (18 month(s) ago) Carotid Artery Stenting posted on: sat,nov 2010 posted by : manuheart123 Carotid artery stenting is a very effective procedure which helps to prevent heart attack, stroke or any other problem. The main purpose of performing carotid artery stenting is to restore adequate flow of blood. This procedure is excellent for people who cannot undergo carotid endarterectomy surgery. Complexity involved in Carotid Artery Stenting There are a certain number of issues or risks involved in CAS. They are: Unexpected shutting down of the artery Reduces heart rate Reduced blood pressure There is a possibility of clots to form within the stent Risks of developing a stroke Hyperperfusion may also occur http://www.heart-consult.com/articles/carotid-artery-stenting Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Carotid Artery Stenting (CAS)Endovascular Course : Carotid Artery Stenting (CAS)Endovascular Course Rashad Bishara MS FRCS General Organization of Teaching Hospitals and Institutes, Egypt (GOTHI) CEA Vs Medical Treatment : CEA Vs Medical Treatment European Carotid Surgery Trial (ECST) North American Carotid Endarterectomy Trial (NASCET) Asymptomatic Carotid Artery Stenosis Trial (ACAS) Carotid EndarterectomyIndications : Carotid EndarterectomyIndications Symptomatic patients > 50% stenosis Asymptomatic patients > 80% stenosis Carotid Surgery Vs Angioplasty : Carotid Surgery Vs Angioplasty Carotid Angioplasty No risk of anesthesia No risk of cranial nerve injury No risk of bleeding No wound no pain or discomfort Better patient acceptance Carotid Surgery Vs Angioplasty : Carotid Surgery Vs Angioplasty Carotid Angioplasty Carotid balloon angioplasty Carotid Stenting Carotid Stenting with protection Carotid Surgery Vs Angioplasty : Carotid Surgery Vs Angioplasty CAVATAS STUDY Lancet. 2001 Jun 2;357(9270):1722-3. Randomized 500 patients Surgery Vs Endovascular Carotid Surgery Vs Angioplasty : Carotid Surgery Vs Angioplasty CAVATAS STUDY RESULTS Major stroke or death: 6.4% Vs 5.9 Any stroke > 7 days: 10% Vs 9.9% Late ipsilateral stroke: No difference Carotid Surgery Vs Angioplasty : Carotid Surgery Vs Angioplasty Endovascular Group: Balloon Angioplasty alone 74% No protection device Slide 9: Carotid Artery Stent Carotid Surgery Vs Stent : Carotid Surgery Vs Stent 5 Year prospective analysis of CAS Roubin GS et al Circulation. 2001 Nov 27;104(22):E121-2. 528 patients Results Mortality 1.6% Major Stroke 1% Minor stroke 4.8% Slide 11: Protection Devices Is Protection Necessary? : Is Protection Necessary? Macroscopic particles are released from each plaque stented Ohki T et al. J Vasc Surg 1998; 27:463-71 Is Protection Necessary? : Is Protection Necessary? CAS accompanied by 4 fold higher rates of HITS Compared with CEA Jordan WD Jr et al. Cardiovasc Surg 1999;7:33-8 Is Protection Necessary? : Is Protection Necessary? 70 CAS without protection Evaluated with MRI New cerebral emboli Demonstrated in 29% of patients Jaeger HJ, Mathias KD et al. Am J Neuroradiol 2002;23:2000-7 Is Protection Necessary? : Is Protection Necessary? High incidence of neurological complications reported if protection is not used: Leicester Trial CEA vs. CAS Stopped after 17 patients 5 out of 7 CAS suffered neurological events Naylor AR et al. J Vasc Surg 1998;28:326-34 Is Protection Necessary? : Is Protection Necessary? High incidence of neurological complications reported if protection is not used: Wallstent Trial CEA vs. CAS Stopped after 219 symptomatic patients Stroke + death 4.5% CEA vs. 12.1 CAS Alberts MJ. Stroke 2001;32:325d Is Protection Necessary? : Is Protection Necessary? Safety & Efficacy of Protection Devices Parodi 45 CAS, 25 with protection 2 neurological events (9.5%) in the unprotected group Vs 0% with protection Parodi JC et al. J Vasc Surg 2000;32:1127-36 Is Protection Necessary? : Is Protection Necessary? Safety & Efficacy of Protection Devices Henry 315 CAS 165 without protection & 150 with protection Henry M et al. Tex Heart Inst J 2000;27:150-8 Is Protection Necessary? : Is Protection Necessary? Safety & Efficacy of Protection Devices Al-Mubarak & Roubin 39 CAS without protection Vs 37 with distal balloon protection Distal balloon protection significantly reduced the Doppler detected microemboli Al-Mubarak N, Roubin GS et al. Circulation 2001; 104:1999-2002 Types of Protection Devices : Types of Protection Devices Distal Balloon PercuSurge GuardWire (Medtronic) Filter Devices Angioguard (Cordis) Proximal Balloon Parodi Antiembolization System (ArteriaA) Slide 21: Medtronic/Percusurge GuardWire Balloon Protection System Slide 22: Embolic Protection, Inc. (EPI) Filterwire EX Embolic Protection, Inc. (EPI) Filterwire EX : Embolic Protection, Inc. (EPI) Filterwire EX Slide 24: Cordis/J&J Angioguard Filter Slide 25: Guidant Accunet Embolic Protection System Slide 26: Intratherapeutics IntraGuard Micro Filter Slide 27: Medtronic AVE, Inc. Embolic Distal Protection Device Slide 28: Mednova, Inc. Cardioshield Filter Angioguard XP Filter Cordis : Angioguard XP Filter Cordis 0.014 wire with a filter at distal end Basket with 8 Nitinol struts, Polyurethane membrane 100 micron pores Diameters 4 to 8mm 4 radio-opaque markers Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Delivery sheath Crossing profile 3.2-3.9F Capture sheath Problems with Protection Devices : Problems with Protection Devices Procedure lengthier & more complicated Need for predilatation Need for buddywire Spasm at protection site Balloon intolerance Problems with Protection Devices : Problems with Protection Devices Ohki et al: 31 CAS using 3 different protection devices PercuSurge Angioguard Parodi Need for predilatation 1/19 2 /7 0/4 Need for buddy wire 2/19 0/7 0/4 Spasm at protection site 4/19 2/7 0/4 Intolerance 0/19 0/7 0/4 Ohki T et al. J Vasc Surg 2002; 36:1175-85 CAS with protection Vs No Protection : CAS with protection Vs No Protection Global CAS Registry (GCASR) Sept 2003: 15,000 CAS Karl Mathieus CIRSE Sept 2003 Wholey MH, Al-Mubarek N et al Catheter Cardiovasc Interv 2003; 60:259-66. CAS with protection Vs No Protection : CAS with protection Vs No Protection CAS with protection Vs No Protection : CAS with protection Vs No Protection Global CAS Registry (GCASR) CAS with protection Vs CEA : CAS with protection Vs CEA SAPPHIRE STUDY Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy CAS with protection Vs CEA In High Risk Patients CAS with protection Vs CEA : CAS with protection Vs CEA SAPPHIRE STUDY Results CAS CEA Patients 156 151 Death & stroke rate 6.9% 12.6% Presented in CIRSE Antalia Sept 2003 American Heart Journal (In-print) CAS with protection Vs CEA : CAS with protection Vs CEA SAPPHIRE STUDY Results Randomized 307 Refused for surgery (had CAS) 409 Refused for CAS (had CEA) 7 Total 723 CAS with protection Vs CEA : CAS with protection Vs CEA SAPPHIRE STUDY Results CAS SUPERIOR TO CEA In High Risk Patients Presented in CIRSE Antalia Sept 2003 American Heart Journal (In-print) CAS with protection Vs CEA : CAS with protection Vs CEA Ongoing Trial For low risk patients Carotid Revascularization vs Stenting Trial (CREST) CEAin Low-Volume Carotid Practice : CEAin Low-Volume Carotid Practice Low-volume carotid practice In Egypt / Middle East Low incidence of carotid disease Low level of disease detection Fear from surgery CEAin Low-Volume Carotid Practice : CEAin Low-Volume Carotid Practice Results of CEA In Low Volume Hospitals Influence of age and hospital volume on the results of carotid endarterectomy: A statewide analysis of 9918 cases B. A. Perler et al JVS 1998 CASin Low-Volume Carotid Practice : CASin Low-Volume Carotid Practice CAS Initial Experience Cases Death Stroke Grube E. Feb 2003 36 0 0 Ohki T. Dec 2002 31 0 1 KJaul U Mar 2001 15 0 1(minor) Parodi JC Dec 2000 25 0 0 CASin Low-Volume Carotid Practice : CASin Low-Volume Carotid Practice GOTHI Vascular Group CAS Experience Number 14 Age 65.5 (56-82) Gender 7M : 7F Symptomatic All Co-morbidities All Stenosis 79.2% (60-95%) CASin Low-Volume Carotid Practice : CASin Low-Volume Carotid Practice GOTHI Vascular Group CAS Experience Tortuous anatomy 2 SMART stent (Cordis) 8 Wallstent (Boston Sc) 3 Expander (Medtronic) 1 Angioguard (Cordis) 11/12 CASin Low-Volume Carotid Practice : CASin Low-Volume Carotid Practice GOTHI Vascular Group CAS Experience Results Mortality 0 Major Stroke 0 Minor stroke 0 TIA 2 CASin Low-Volume Carotid Practice : CASin Low-Volume Carotid Practice GOTHI Vascular Group CAS Experience Results Re-stenosis: 0 (2 -27 months) Summary : Summary CAS is superior to CEA in high risk patients CEA carries high risk of complications and death in low volume carotid practice Initial experiences with CAS did not show bad results CASIn Egypt : CASIn Egypt CAS Technique : CAS Technique Sheath 7F Selective catheterization of CCA Headhunter Cobra MPA Simmons Road map of carotid bifurcation CAS Technique : CAS Technique Selective catheterization of ECA Terumo 0.035 X 260cm stiff Remove catheter leaving wire in ECA Guiding sheath Carotid or MP Protection device through guiding sheath into ICA CAS Technique : CAS Technique Open protection device Patient must be heparinized Reduce filtering time Pre-dilatation in tight lesions 3mm X 2cm balloon Stent Self expanding 9mm X 3cm Dilate stent 5 to 6mm X 2cm balloon CAS Technique : CAS Technique Retrieve protection device Retrieval sheath Balloon Completion angio ? Intracranial angio Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips Use coronary balloon for pre-dilatation Position the filter well beyond the lesion Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips Position the filter in the distal ICA Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips 3. Open the filter by removing the delivery sheath Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips 4. Check filter patency regularly Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips 5. If filter is full of debris: Complete the procedure & retrieve filter Or Aspirate, Retrieve the filter, Deploy a new filter Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips 6. Stabilize the filter during the procedure Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips 7. Retrieve filter using 5F balloon catheter ? CAS Drugs : CAS Drugs Preoperative: Aspirin Plavix Intra-operative: Heparin Atropine Nitroglycerine ? TPA ? CAS Drugs : CAS Drugs Post-operative: Monitor for hypotension Monitor for bradycardia CASFollow up : CASFollow up Duplex surveillance: Immediate 1 month 3 months 6 months 12 months 18 months 24 months yearly CASGOTHI experience : CASGOTHI experience Carotid Stent after 2 years You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Carotid artery stenting endovascular course March 04 MOHAMEDOMAR Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 355 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: August 28, 2010 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... By: manuheart123 (18 month(s) ago) Carotid Artery Stenting posted on: sat,nov 2010 posted by : manuheart123 Carotid artery stenting is a very effective procedure which helps to prevent heart attack, stroke or any other problem. The main purpose of performing carotid artery stenting is to restore adequate flow of blood. This procedure is excellent for people who cannot undergo carotid endarterectomy surgery. Complexity involved in Carotid Artery Stenting There are a certain number of issues or risks involved in CAS. They are: Unexpected shutting down of the artery Reduces heart rate Reduced blood pressure There is a possibility of clots to form within the stent Risks of developing a stroke Hyperperfusion may also occur http://www.heart-consult.com/articles/carotid-artery-stenting Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Carotid Artery Stenting (CAS)Endovascular Course : Carotid Artery Stenting (CAS)Endovascular Course Rashad Bishara MS FRCS General Organization of Teaching Hospitals and Institutes, Egypt (GOTHI) CEA Vs Medical Treatment : CEA Vs Medical Treatment European Carotid Surgery Trial (ECST) North American Carotid Endarterectomy Trial (NASCET) Asymptomatic Carotid Artery Stenosis Trial (ACAS) Carotid EndarterectomyIndications : Carotid EndarterectomyIndications Symptomatic patients > 50% stenosis Asymptomatic patients > 80% stenosis Carotid Surgery Vs Angioplasty : Carotid Surgery Vs Angioplasty Carotid Angioplasty No risk of anesthesia No risk of cranial nerve injury No risk of bleeding No wound no pain or discomfort Better patient acceptance Carotid Surgery Vs Angioplasty : Carotid Surgery Vs Angioplasty Carotid Angioplasty Carotid balloon angioplasty Carotid Stenting Carotid Stenting with protection Carotid Surgery Vs Angioplasty : Carotid Surgery Vs Angioplasty CAVATAS STUDY Lancet. 2001 Jun 2;357(9270):1722-3. Randomized 500 patients Surgery Vs Endovascular Carotid Surgery Vs Angioplasty : Carotid Surgery Vs Angioplasty CAVATAS STUDY RESULTS Major stroke or death: 6.4% Vs 5.9 Any stroke > 7 days: 10% Vs 9.9% Late ipsilateral stroke: No difference Carotid Surgery Vs Angioplasty : Carotid Surgery Vs Angioplasty Endovascular Group: Balloon Angioplasty alone 74% No protection device Slide 9: Carotid Artery Stent Carotid Surgery Vs Stent : Carotid Surgery Vs Stent 5 Year prospective analysis of CAS Roubin GS et al Circulation. 2001 Nov 27;104(22):E121-2. 528 patients Results Mortality 1.6% Major Stroke 1% Minor stroke 4.8% Slide 11: Protection Devices Is Protection Necessary? : Is Protection Necessary? Macroscopic particles are released from each plaque stented Ohki T et al. J Vasc Surg 1998; 27:463-71 Is Protection Necessary? : Is Protection Necessary? CAS accompanied by 4 fold higher rates of HITS Compared with CEA Jordan WD Jr et al. Cardiovasc Surg 1999;7:33-8 Is Protection Necessary? : Is Protection Necessary? 70 CAS without protection Evaluated with MRI New cerebral emboli Demonstrated in 29% of patients Jaeger HJ, Mathias KD et al. Am J Neuroradiol 2002;23:2000-7 Is Protection Necessary? : Is Protection Necessary? High incidence of neurological complications reported if protection is not used: Leicester Trial CEA vs. CAS Stopped after 17 patients 5 out of 7 CAS suffered neurological events Naylor AR et al. J Vasc Surg 1998;28:326-34 Is Protection Necessary? : Is Protection Necessary? High incidence of neurological complications reported if protection is not used: Wallstent Trial CEA vs. CAS Stopped after 219 symptomatic patients Stroke + death 4.5% CEA vs. 12.1 CAS Alberts MJ. Stroke 2001;32:325d Is Protection Necessary? : Is Protection Necessary? Safety & Efficacy of Protection Devices Parodi 45 CAS, 25 with protection 2 neurological events (9.5%) in the unprotected group Vs 0% with protection Parodi JC et al. J Vasc Surg 2000;32:1127-36 Is Protection Necessary? : Is Protection Necessary? Safety & Efficacy of Protection Devices Henry 315 CAS 165 without protection & 150 with protection Henry M et al. Tex Heart Inst J 2000;27:150-8 Is Protection Necessary? : Is Protection Necessary? Safety & Efficacy of Protection Devices Al-Mubarak & Roubin 39 CAS without protection Vs 37 with distal balloon protection Distal balloon protection significantly reduced the Doppler detected microemboli Al-Mubarak N, Roubin GS et al. Circulation 2001; 104:1999-2002 Types of Protection Devices : Types of Protection Devices Distal Balloon PercuSurge GuardWire (Medtronic) Filter Devices Angioguard (Cordis) Proximal Balloon Parodi Antiembolization System (ArteriaA) Slide 21: Medtronic/Percusurge GuardWire Balloon Protection System Slide 22: Embolic Protection, Inc. (EPI) Filterwire EX Embolic Protection, Inc. (EPI) Filterwire EX : Embolic Protection, Inc. (EPI) Filterwire EX Slide 24: Cordis/J&J Angioguard Filter Slide 25: Guidant Accunet Embolic Protection System Slide 26: Intratherapeutics IntraGuard Micro Filter Slide 27: Medtronic AVE, Inc. Embolic Distal Protection Device Slide 28: Mednova, Inc. Cardioshield Filter Angioguard XP Filter Cordis : Angioguard XP Filter Cordis 0.014 wire with a filter at distal end Basket with 8 Nitinol struts, Polyurethane membrane 100 micron pores Diameters 4 to 8mm 4 radio-opaque markers Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Delivery sheath Crossing profile 3.2-3.9F Capture sheath Problems with Protection Devices : Problems with Protection Devices Procedure lengthier & more complicated Need for predilatation Need for buddywire Spasm at protection site Balloon intolerance Problems with Protection Devices : Problems with Protection Devices Ohki et al: 31 CAS using 3 different protection devices PercuSurge Angioguard Parodi Need for predilatation 1/19 2 /7 0/4 Need for buddy wire 2/19 0/7 0/4 Spasm at protection site 4/19 2/7 0/4 Intolerance 0/19 0/7 0/4 Ohki T et al. J Vasc Surg 2002; 36:1175-85 CAS with protection Vs No Protection : CAS with protection Vs No Protection Global CAS Registry (GCASR) Sept 2003: 15,000 CAS Karl Mathieus CIRSE Sept 2003 Wholey MH, Al-Mubarek N et al Catheter Cardiovasc Interv 2003; 60:259-66. CAS with protection Vs No Protection : CAS with protection Vs No Protection CAS with protection Vs No Protection : CAS with protection Vs No Protection Global CAS Registry (GCASR) CAS with protection Vs CEA : CAS with protection Vs CEA SAPPHIRE STUDY Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy CAS with protection Vs CEA In High Risk Patients CAS with protection Vs CEA : CAS with protection Vs CEA SAPPHIRE STUDY Results CAS CEA Patients 156 151 Death & stroke rate 6.9% 12.6% Presented in CIRSE Antalia Sept 2003 American Heart Journal (In-print) CAS with protection Vs CEA : CAS with protection Vs CEA SAPPHIRE STUDY Results Randomized 307 Refused for surgery (had CAS) 409 Refused for CAS (had CEA) 7 Total 723 CAS with protection Vs CEA : CAS with protection Vs CEA SAPPHIRE STUDY Results CAS SUPERIOR TO CEA In High Risk Patients Presented in CIRSE Antalia Sept 2003 American Heart Journal (In-print) CAS with protection Vs CEA : CAS with protection Vs CEA Ongoing Trial For low risk patients Carotid Revascularization vs Stenting Trial (CREST) CEAin Low-Volume Carotid Practice : CEAin Low-Volume Carotid Practice Low-volume carotid practice In Egypt / Middle East Low incidence of carotid disease Low level of disease detection Fear from surgery CEAin Low-Volume Carotid Practice : CEAin Low-Volume Carotid Practice Results of CEA In Low Volume Hospitals Influence of age and hospital volume on the results of carotid endarterectomy: A statewide analysis of 9918 cases B. A. Perler et al JVS 1998 CASin Low-Volume Carotid Practice : CASin Low-Volume Carotid Practice CAS Initial Experience Cases Death Stroke Grube E. Feb 2003 36 0 0 Ohki T. Dec 2002 31 0 1 KJaul U Mar 2001 15 0 1(minor) Parodi JC Dec 2000 25 0 0 CASin Low-Volume Carotid Practice : CASin Low-Volume Carotid Practice GOTHI Vascular Group CAS Experience Number 14 Age 65.5 (56-82) Gender 7M : 7F Symptomatic All Co-morbidities All Stenosis 79.2% (60-95%) CASin Low-Volume Carotid Practice : CASin Low-Volume Carotid Practice GOTHI Vascular Group CAS Experience Tortuous anatomy 2 SMART stent (Cordis) 8 Wallstent (Boston Sc) 3 Expander (Medtronic) 1 Angioguard (Cordis) 11/12 CASin Low-Volume Carotid Practice : CASin Low-Volume Carotid Practice GOTHI Vascular Group CAS Experience Results Mortality 0 Major Stroke 0 Minor stroke 0 TIA 2 CASin Low-Volume Carotid Practice : CASin Low-Volume Carotid Practice GOTHI Vascular Group CAS Experience Results Re-stenosis: 0 (2 -27 months) Summary : Summary CAS is superior to CEA in high risk patients CEA carries high risk of complications and death in low volume carotid practice Initial experiences with CAS did not show bad results CASIn Egypt : CASIn Egypt CAS Technique : CAS Technique Sheath 7F Selective catheterization of CCA Headhunter Cobra MPA Simmons Road map of carotid bifurcation CAS Technique : CAS Technique Selective catheterization of ECA Terumo 0.035 X 260cm stiff Remove catheter leaving wire in ECA Guiding sheath Carotid or MP Protection device through guiding sheath into ICA CAS Technique : CAS Technique Open protection device Patient must be heparinized Reduce filtering time Pre-dilatation in tight lesions 3mm X 2cm balloon Stent Self expanding 9mm X 3cm Dilate stent 5 to 6mm X 2cm balloon CAS Technique : CAS Technique Retrieve protection device Retrieval sheath Balloon Completion angio ? Intracranial angio Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips Use coronary balloon for pre-dilatation Position the filter well beyond the lesion Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips Position the filter in the distal ICA Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips 3. Open the filter by removing the delivery sheath Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips 4. Check filter patency regularly Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips 5. If filter is full of debris: Complete the procedure & retrieve filter Or Aspirate, Retrieve the filter, Deploy a new filter Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips 6. Stabilize the filter during the procedure Angioguard XP Filter Cordis : Angioguard XP Filter Cordis Important Tips 7. Retrieve filter using 5F balloon catheter ? CAS Drugs : CAS Drugs Preoperative: Aspirin Plavix Intra-operative: Heparin Atropine Nitroglycerine ? TPA ? CAS Drugs : CAS Drugs Post-operative: Monitor for hypotension Monitor for bradycardia CASFollow up : CASFollow up Duplex surveillance: Immediate 1 month 3 months 6 months 12 months 18 months 24 months yearly CASGOTHI experience : CASGOTHI experience Carotid Stent after 2 years