bluuebunny/crossref_metadata_2025 huggingface dataset:
P-021 A randomized trial comparing platinum and hydrogel-coated coils in patients prone to recurrence after endovascular treatment—the PRET trial: Abstract P-021 Figure 1
Authors: Raymond J , Roy D , Weill A
Published: July 2012

Purpose

The PRET trial aims compares hydrocoils to bare platinum coils in patients with aneurysms prone to recurrence, that is, in patients with large aneurysms (≥10 mm; PRET-1 patients) or in patients with a major recurrence after previous coiling (PRET-2 patients). We aim at reporting an update of the randomization rate and results of the interim analysis from the DMSC.

Materials and Methods

PRET is a RCT with single-blind allocation. 500 subjects are followed for 18 months. PRET-1 (250) and PRET-2 (250) cases are randomized separately. Interventions are : a/bare coil embolization, or b/hydrocoil embolization. Primary endpoint is recurrence rate. Secondary endpoints include procedural complications, clinical outcome, safety of hydrogel coiling and overall M&M.

Results

344 PRET subjects were randomized by 33 sites in Canada, US, France, UK, Japan and Chile. Baseline characteristics of the first 264 PRET subjects were (mean (SD)): Age = 59 (11) years; 73% had only one aneurysm; 16% presented with acute rupture of the aneurysm; Aneurysm parameters for PRET1 subjects (53%) were: size = 14 (5) mm and in 57% of cases located in the anterior circulation. Aneurysm parameters for PRET2 subjects (47%) were: size = 13 (11) mm and in 57% of cases located in the anterior circulation. An interim safety analyses carried out on 234 subjects did not reveal any significant difference in SAEs or clinical outcome (mRS>2 at discharge and 1-month follow-up) between treatment arms.

Conclusion

We hope that PRET will show that for the treatment of aneurysms prone to recurrence, Hydrocoils provide an equal or higher efficacy than bare platinum coils with no difference in safety profile.

Competing interests

J Raymond: Microvention Inc. (investigator-led clinical trial funding for PRET). D Roy: None. A Weill: None.

Abstract P-021 Figure 1
P-028 Clinical experience and lessons learned with the penumbra PC 400 large volume coil: improving the treatment of both large and small aneurysms
Authors: Baxter B , Quarfordt S
Published: July 2012

Objective

We report our clinical experience in treating 34 aneurysms in 29 patients using the Penumbra PC400 Large Volume Coil.

Clinical presentation and treatment

Our treatment population consisted of four large (10–25 mm) and 30 small (<10 mm) aneurysms. Nine were ruptured and 25 unruptured. Aneurysm location was 24 anterior circulation vs 10 posterior circulation. For the small aneurysms the average aneurysm size was 5.4 mm, average of 2.1 coils/aneurysm, and 48.9% average packing density. For the large aneurysms the average aneurysm size was 11.5 mm and 31.2% average packing density. An average of 5.6 coils were placed in three of the large aneurysms that were treated with only the PC400 coils. One of the large aneurysms had been previously treated with five GDC coils and then three Penumbra coils were used to treat recurrent aneurysm. Two patients had a stent placed across the aneurysm neck during a separate procedure performed prior to coiling and two patients had a stent placed during the coil procedure. One patient with a ruptured Left SCA aneurysm experienced a non-disabling Left PCA infarct giving a 2.9 % complication rate. Six month follow-up performed in 14 aneurysms.

Conclusion

Our clinical experience with the PC400 Coil system has demonstrated this 0.020′ coil and 025 ID deployment catheter to be safe and efficacious in treating both small and large aneurysms. Using the PC400 Large Volume Coil results in a higher packing density while using fewer coils. The use of fewer coils has proven to reduce case time and procedural costs. Follow-up data suggest that the use of the coils produced durable occlusions. The softness by design of this large volume coil combined with the improved body of the deployment catheter has markedly improved the treatment of both large and small aneurysms.

Competing interests

B Baxter: Stryker, ev3.
P-031 Mechanical thrombectomy with the solitaire device: is there a learning curve toward achieving rapid recanalization times?: Abstract P-031 Figure 1
Authors: Eesa M , Almekhlafi M , Menon B , Wong J , Demchuk A , Goyal M
Published: July 2012

Introduction/Purpose

We evaluated recanalization times with the Solitaire device in patients undergoing endovascular acute ischemic stroke therapy at our institution.

Materials and Methods

We reviewed patients who presented to our stroke center and in whom a Solitaire device was used for revascularization. Demographic data and stroke severity were obtained from chart review. Time points for CT scanning, angiography arrival, puncture, time of first deployment of the device and recanalization times were recorded from time-stamped PACS images and angiography records. Time intervals were calculated (CT to angiography arrival, angiography arrival to puncture, puncture to first deployment and deployment to recanalization). To evaluate time interval trends, recanalized patients were sequentially divided into three sequential groups. Overall CT to recanalization time and interval times between groups were compared using an analysis-of-variance (ANOVA) test. In addition, we also looked for difference between groups using the Scheffe's test correcting for multiple comparisons. All tests are two sided with a p value <0.05 considered to be statistically significant. Analysis was performed using Stata® V.12.

Results

83 patients (38 female; mean age: 65.7±14.3) were treated with the Solitaire device from May 2009 to February 2012. The median NIHSS was 17. Recanalization (TIMI 2/3) occurred in 75 (90.4%) patients. CT to recanalization time showed a statistically significant decrease over time (p<0.01). This difference was maximal between first 25 and most recent 25 cases (161 to 94 min, p<0.01). The maximal contribution to this was from improvements in first deployment to recanalization time between the first 25 and second 25 patients (p=0.01) and between the first and third 25 patients (p=0.001) with modest contributions from moving patients from CT to the angiography-suite faster (p=0.02 between 1st and 3rd groups) and from puncture to first deployment (p=0.02 between 1st and 3rd groups). There was no statistically significant difference in time from angiography-suite arrival to puncture between the groups (Abstract P-031 figure 1).

Abstract P-031 Figure 1

Conclusion

There appears to be a learning curve involved in the efficient use of the Solitaire device in endovascular acute stroke therapy. Along with slight improvements in moving patients to angiography sooner and improved efficiency with intracranial access, mastering this device contributed significantly toward the overall drive to reduce recanalization times in stroke patients treated by an endovascular approach at our institution. This needs to be validated in a prospective manner to understand components of this learning curve that is potentially useful to educate new users to achieve faster recanalization times.

Competing interests

None.
E-001 Estimation of stent conformity for cerebrovascular stent with patient-specific curved arterial model
Authors: Shobayashi Y , Tateshima S , Tanishita K , Viñuela F
Published: July 2012

Introduction

Clinically, adaptation of an implanted stent to the vessel wall influences the development of problems such as intimal hyperplasia and in-stent-stenosis for intracranial stenting. In particular, for the stenting in a curved vessel, it was indicated that a stent deployed across an artery with angulation exerts a certain longitudinal rebounding cause of vessel straightening. For this reason, it is necessary to investigate stent-artery interaction including stress distribution and vessel deformation due to stent designs within the realistic curved arterial model.

Materials and Methods

The aim of this study is to analyze and evaluate the stress distribution within the stented curved artery using open and closed-cell stent designs. We focused on stent geometries and calculated the differences in stress within the realistic curved artery due to the structure and stent position using deformation analysis with finite element modeling.

Results

The results have different stress behavior by stent designs and its position within the parent artery. High stress values were obtained in the curved portion and at the proximal section of the parent artery with the area of contact between stent strut and the artery for all models. This behavior could be explained by differences the metal-to-artery ratio on each side of proximal and distal vessel according to stent position. Furthermore, vessel straightening was obtained for curved section with stented artery due to longitudinal rebounding force of the stent. Comparing the distribution of high stress area for stent designs, open-cell stent has lager area of high stresses than closed-cell stent at distal portion. In the other hand, the stress distribution of closed-cell was similar for different stent position.

Conclusion

For our simulation, stent behavior such as stress status and vessel deformation was varied by stent design and its position within the curved artery. This numerical method might be effective for designing a better stent specifically for the intracranial stenting and also to select an appropriate stent prior to the actual endovascular procedure.

Competing interests

None.
E-011 Wingspan stent for symptomatic intracranial stenosis: a single center analysis
Authors: Baxter B , Quarfordt S , Hungerford J , Kline A , Maass G , Huang X
Published: July 2012

Background

The role of Wingspan stent placement for the treatment of symptomatic intracranial stenosis has been greatly questioned in the wake of the SAMMPRIS trial results, which found a disparity between its treatment arms of medical management with Wingspan stenting and medical management alone for stroke or death at 30 days. The 30-day and 1-year probabilities of the primary endpoint of the SAMMPRIS trial (any stroke or death within 30 days or ischemic stroke in the territory of the qualifying artery beyond 30 days) were 5.8% and 12.2% for the medical management arm and 14.7% and 20.0% for the Wingspan arm, respectively.

Purpose

The purpose of this real world study was to evaluate patient outcomes at Erlanger Medical Center who received a Wingspan stent and compare to the SAMMPRIS trial results.

Methods

This was a retrospective cohort analysis of Wingspan stent use for symptomatic intracranial stenosis of a major cerebral artery and compared single center Wingspan group outcomes to those reported for medical management alone from the multi-center SAMMPRIS trial. Consistent with SAMMPRIS, the primary endpoint was any stroke or death within 30 days, or ischemic stroke in the territory of the qualifying artery beyond 30 days.

Results

With a mean follow-up period of 2.1 years, the 30-day and 1-year probabilities of the primary endpoint were both 10.4% (n=42). Patient characteristics associated with higher risks of adverse events included female sex, diabetes mellitus, location of stent placement, and severity of the offending stenosis.

Conclusion

Outcomes after Wingspan stenting at this single medical center were only inferior to those from the SAMMPRIS medical management arm at 30 days, but not at 1 year. Outcomes at 30 days and 1 year were both lower than those reported from the SAMMPRIS Wingspan arm and seem to be more consistent with those previously published from other Wingspan registries. Unlike the SAMMPRIS trial results, there was no increase in the probability of the primary endpoint between 30 days and 1 year. This real world experience suggests that the role of Wingspan stenting needs further investigation, and continued evaluation of intracranial stenting for symptomatic intracranial stenosis seems worthwhile.

Competing interests

B Baxter: Stryker Neurovascular, Penumbra, Codman, EV3, Rapid Medical, Reverse Medical. S Quarfordt: None. J Hungerford: None. A Kline: None. G Maass: None. X Huang: None.
E-012 Urgent intra-arterial thrombectomy for stroke: technical complications
Authors: de Miquel M , Aja L , Mora P , Aixut S , Cardona P , Quesada H , Rubio F , Barranco R
Published: July 2012

Introduction

Since April 2010, a pilot experience has been set for offering intra-arterial treatment for stroke to a 3.5 million people population. We aim to share our experience from the standpoint of technical complications.

Material and Methods

The review of 122 patients (69 male and 53 female, mean age 65,4 years) show that twelve cases presented technical complications.

In four patients, distal emboli to other territories than the occluded vessel were seen. Two of them were not specifically treated and showed a bad outcome, while the other two were successfully treated with good final Rankin Score.

Hemorrhage during microcateterization was noted in four patients. Even though the bleeding was controlled with glue or coils, bad outcome was noted in those patients.

One patient presented a femoral pseudoaneurysm related to the puncture site, with severe bleeding and other co-morbidity leading to death.

Carotid stent issues in tandem lesions were seen in two patients.

In one case, the thrombectomy device was let in place (M1) due to impossibility to retrieve it.

Some subclinical incidences as balloon rupture (1 case), M1, M2 or M3 vasospasm, easily resolved with intraarterial nimodipine (3 cases) and some degree of vessel dissection without significant caliber reduction (3 cases) were also recorded.

Results and Conclusion

In our series, around a ten percent of intraarterial thrombectomy treatments presented procedure related complications. In our opinion, four of them can be attributed to our learning curve, leading to a theoretical complication risk of around a 7% for technical complications.

Competing interests

None.
E-016 Low cost, efficient, highly effective method for therapeutic arterial occlusion of the internal carotid or vertebral artery with flow control
Authors: Heck D
Published: July 2012

Therapeutic internal carotid or vertebral artery occlusion is occasionally recommended for a variety of cerebrovascular diseases, including giant aneurysms, vessel ruptures, and arteriovenous fistulae. With the removal of detachable balloons from the U.S. market, there is no ideal device to occlude a cerebral vessel rapidly and safely. Intracranial occlusion of cerebral vessels presents challenges of vessel tortuosity, and the possibility of cerebral embolization during the process of occluding the artery. Coils designed for endovascular occlusion of brain aneurysms are often used because they are deliverable in the intracranial circulation. However, these products are not highly effective for this application, expensive, and multiple coils are often needed which leads to a high cost procedure. Further, if no flow control is used during the procedure, the potential for cerebral embolization is real as thrombus begins to form at the site of occlusion. When proximal balloon occlusion is used, there is no way to “test” the occlusion short of deflating the balloon. Here presented are two cases, one in the internal carotid artery and one in the vertebral artery, of therapeutic occlusion using balloon occlusion guide catheters for flow arrest in the internal carotid artery, and flow reversal in the vertebral artery. The first patient is a 49 year old who presented with acute pain and cranial nerve III palsy and a giant right cavernous carotid aneurysm, and the second a 69 year old who presented with hearing loss and balance difficulty and a giant dissecting aneurysm of the left vertebral artery. Intracranial occlusion was achieved in each case with Interlock coils (Boston Scientific), a 0.018″ fibered, detachable coil, and then the vessel occluded proximally with an Amplatzer vascular plug (St. Jude Medical) to ensure cessation of flow prior to occlusion balloon deflation. The total cost of embolics in each case was <3000 dollars. The principles outlined are generalizable to a variety of situations where parent vessel occlusion is the desired treatment.

Competing interests

None.
E-019 Novel aneurysm neck reconstruction device: initial experience in an experimental pre-clinical bifurcation aneurysm model: Abstract E-019 Figure 1
Authors: Turk A , Tateshima S , Chaudry M , Fiorella D , Turner R , Kelly M
Published: July 2012

Introduction

Treatment of wide necked bifurcation aneurysms often poses procedural and long-term outcome challenges. We describe the initial preclinical experience with the Pulsar Vascular Aneurysm Neck Reconstruction Device (PVANRD) in a canine bifurcation model.

Methods

Experimental bifurcation vein pouch aneurysms were surgically created in the carotid arteries of eight canines. Endovascular coiling of the aneurysms with assistance of the PVANRD was performed in all cases with acute performance compared to Y-stenting.

Results

12 devices were deployed in the eight cases. Device deployment was straightforward and successfully protected the parent artery and maintained patency of the bifurcation in all cases, despite the use of oversized coils.

Conclusion

The PVANRD is a novel bifurcation stent that facilitates treatment of wide necked bifurcation aneurysms compared with currently available adjunctive devices.

Competing interests

A Turk: Pulsar Vascular. S Tateshima: None. M Chaudry: None. D Fiorella: None. R Turner: None. M Kelly: None.

Abstract E-019 Figure 1
E-002 Acute endovascular therapy in young ischemic stroke patients and the role of intra-arterial vasodilator in the process of recanalization
Authors: Lodi Y , Elzammar Z , Cummins M , Devasenapathy A , Latorre G , Swrankar A
Published: July 2012

Introduction

Endovascular therapy using IA tPA +/- Thrombectomy is an option for those who are either not a candidate or failed IV tPA. However, a little is known about age specific outcome. Our objectives are to describe the radiographic and clinical outcome of young patients (<65) who underwent acute stroke interventional therapy as well as evaluate the role of IA vasodilators in the process of recanalization.

Methods

Consecutive patients underwent acute stroke intervention from 2007 to 2010 were enrolled. Patients demographic, presenting NIHSS, use of IA thrombolytic, vasodilator, and recanalization rate were recorded. Patients' outcome using Glasgow Outcome Scale Score was measured at 30 days.

Results

38 patients (mean age 38±14; median NIHSS 16) received intervention, 11 patients had failed IV tPA. Patients were offered therapy within 8 h except for five cases (stroke at awakening). IA tPA was given in 36, thrombectomy was done in 30, and 21 patients received IA vasodilator (16 Varapamil; 5 Nitroglycerine). Overall recanalization was near to complete in 92%. All patients received IA vasodilator have recanilized (TIMI III 13/21 and TIMI II 8/21).

Overall 30-days outcome

Good was observed in 51% (GOS 5 in 11, GOS 4 in 7), Dependence (GOS 3) in 34%, and Death (GOS 1) in 14%; vasodilators' group showed similar outcome with Good in 42% (7/17), Dependence in 41% (7/17) and Death in 17% (3/17). Poor outcome was associated with high NIHSS and poor recanalization.

Conclusions

Acute endovascular therapy achieves a high rate of recanalization in young acute ischemic stroke. IA vasodilators use during thrombectomy was associated with higher rate of recanalization. Further study is required to evaluate the role of vasodilators in acute stroke interventions.

Competing interests

None.
E-027 Stent graft repair of carotid pseudoaneurysm in a young child with short-term follow-up: Abstract E-027 Figure 1
Authors: Somers S , Basu S , Zouros A , Abou-Zamzam A , Jacobson P
Published: July 2012

Introduction

Traumatic pseudoaneurysm of the carotid artery is a dangerous complication of penetrating trauma. Stent grafting is an accepted treatment; however the youngest reported patient so treated at the time was 11 years old. We report the successful use of stent grafting in the case of a 4-year-old female with carotid pseudoaneurysm from penetrating neck injury.

Clinical Materials and Methods

An otherwise healthy 4-year-old girl presented to an outside ED after accidentally stabbing herself in the neck with a toy fishing pole while using a slide. Physical examination demonstrated a small puncture wound to the right neck and no neurologic deficit. Initial CT examination demonstrated complete occlusion of the right internal carotid artery (RICA). After transfer to our institution, catheter angiography showed a patent RICA with focal 35% stenosis and double wall pseudoaneurysms at the level of C2. Vascular surgery and pediatric neurosurgical consultations indicated that surgical repair was not optimal due to the uncertainty of distal control and the likely need to disarticulate the right TMJ for exposure; stent grafting was requested and preferred to RICA sacrifice. After informed consent for possible off-label stent grafting vs RICA sacrifice, the patient was placed under general anesthesia. After access of both common femoral arteries and heparinization (800 units IV), an angiographic RICA balloon test occlusion showed probably adequate collateral supply to the right anterior circulation. DSA showed interval growth of the anterior and posterior wall RICA pseudoaneurysms and increased stenosis (50%). The decision was taken to stent graft the RICA. A 7F sheath was positioned in the RCCA and a Viabahn 5 mm × 25 mm self-expanding stent graft (Gore) was deployed across the lesion. A minor endoleak from the anterior pseudoaneurysm nearly resolved after balloon dilation of the stent. Hemostasis was obtained manually. Patient was loaded with aspirin and clopidogrel (16 mg) after the procedure for a 1-month course.

Results

The patient was neurologically intact after the procedure with preservation of her right pedal pulses. Baseline postprocedure duplex and MRA showed wide patency of the stent graft without visible endoleak. Repeat duplex at 8 weeks redemonstrated wide patency of the graft and occlusion of the pseudoaneurysms. On a clinic visit at 10 weeks, the neurological examination was normal, no neck bruit was audible, and the right pedal pulses were 2+.

Conclusion

Carotid stent graft is a viable treatment option for traumatic pseudoaneurysm in children as young as 4 years of age.

Competing interests

None.

Abstract E-027 Figure 1
E-034 Stent assistance in neurointerventional procedures
Authors: Buciuc R , Luzardo G
Published: July 2012

Introduction

Balloon assistance for endovascular management of intracranial aneurysms is an established technique. There are possible limitations to this technique related to either anatomical or functional factors (patient intolerance to baloon occlusion). The authors present their experience using a retrievable intracranial stent as an assistive device for either coiling of aneurysms or navigation or microcatheters in difficult anatomy.

Methods

A total of three patients underwent neurointerventions using a retrievable stent assistance technique. Two patients had intracranial aneurysms, one at the posterior communicating segment level and the other supraclinoid. An additional patient with a posterior circulation AVM underwent stent-assisted navigation of a microcatheter for Onix embolization of the malformation. In all cases the stent was partially deployed and used only to assist either in coil placement or in navigation of the microcatheter through a tortuous PICA. In one aneurysm case the carotid was anatomically isolated, therefore it has been percieved that temporary baloon occlusion might be exposing the patient to irreversible ischemia. In the other aneurysm case the intent was to withdraw the stent after assistance due to possible difficult post-op management of antiplatelet therapy. In the AVM case the stent was used after and attempt of using balloon assistance for navigation failed. None of the patients who underwent stent assistance, received antiplatelets in advance. Should the stent not have been retrieved, emergent antiplatelet therapy would have been initiated.

Results

In all three cases the stent was retrieved successfully and contributed to effective management of the case. There were no complications related to the stent usage.

Conclusion

The usage of stent assistance in neurointerventional cases has a potential use for situations in which balloon assistance is not possible or unsuccessful. A larger series of cases is however necessary to demonstrate safety and reproducibility of this technique

Competing interests

None.
E-037 Midterm outcomes of endovascular treatment in unruptured superiorly projecting paraclinoid aneurysms
Authors: Matsumoto Y , Kondo R
Published: July 2012

Purpose

In the treatment of superiorly projecting paraclinoid aneurysms (SPP ANs), coil embolization (CE) has been considered inferior to surgical clipping (SC) because of the high rates of recanalization and ischemic complication. However, innovation of endovascular technology could overcome such disadvantages. This study was designed to evaluate recent results of CE in SPP ANs.

Materials and Methods

43 consecutive patients with unruptured SPP ANs treated between 2004 and 2010 were retrospectively reviewed. SPP ANs include ophthalmic ANs and anterior wall ANs (AW ANs). Ophthalmic ANs arise at the junction of the ophthalmic artery and the internal carotid artery (ICA). AW ANs superiorly arise from the supraclinoid ICA without branching arteries. Midterm angiographic outcomes and complication rate were compared between CE and SC.

Results

33 patients underwent CE and 10 patients underwent SC. The CE group included 30 small ANs (<12 mm) and three large ANs (12–25 mm). The SC group included eight small ANs and two large ANs. In the CE group, recanalization was observed in two large ANs (6.1%) for a mean follow-up period of 27.2 months. Small ANs did not reveal recanalization. One of the recanalised ANs underwent a second CE and no recanalization was observed for 12 months after retreatment. The other received parent artery occlusion. In the SC group, no recanalization was observed during the follow-up period (mean: 32.9 months). Procedure-related morbidity was 2.9% (1/33) in the CE group and 10.0% (1/10) in the SC group.

Conclusion

Coil embolization for SPP ANs was equivalent to SC in terms of midterm durability and safety, particularly for small ANs.

Competing interests

None.
E-039 Impact of contrast load for acute ischemic stroke endovascular therapy on renal function
Authors: Noorian A , Rangaraju S , Owada K , Glenn B , Belagaje S , Anderson A , Frankel M , Gupta R , Nogueira R
Published: July 2012

Background

To date, there have not been any studies to evaluate the effect of contrast load given during endovascular revascularization on renal function in acute ischemic stroke (AIS) patients.

Objective

The aim of this study was to evaluate the effect of contrast load on the Creatinine (Cr) levels of AIS patients undergoing endovascular treatment.

Design/methods

Consecutive AIS patients in Grady Memorial Hospital were retrospectively analyzed. The AIS transfers from outside hospitals were excluded from this study given uncertainty about prior contrast load and in some instances lack of documented Cr levels. Patients' demographic information, baseline NIHSS, site of occlusion, revascularization modalities were collected. The Cr, immediately before (PRE-Cr) and the highest Cr within 72 h after the endovascular procedure (POST-Cr) were recorded. Descriptive statistics are provided.

Results

Forty-three patients (age 68±14; 44% male) with large vessel occlusions were included (25 patients with M1 occlusion, nine patients with M2/3 occlusion, seven patients with ICA occlusion and two patients with basilar/PCA occlusions). The mean NIHSS was 18. Twenty-one percent of the patients were diabetics. Two of the patients had Cr >2.0 at baseline. Sixty percent of the patients had CT Angiography of the head/neck with contrast before the procedure. Patients had PRE and POST Cr of 1.2±0.4 (median: 1.1, IQR: 0.9–1.3) and 1.1±0.5 (median: 1.0, IQR: 0.75–1.2), respectively. None of the 41 patients with baseline Cr <2.0 had Cr elevation >2.0 and only one patient had Cr elevation >50% of baseline. None of two patients with baseline Cr >2.0 had Cr elevation >50% of baseline. None of the patients required dialysis.

Conclusions

Our results suggest that endovascular management of acute stroke has minimal impact in kidney function in the first few days after the procedure.

Competing interests

A Noorian: None. S Rangaraju: None. K Owada: None. B Glenn: None. S Belagaje: None. A Anderson: None. M Frankel: None. R Gupta: Concentric Medical, Codman Neurovascular, CoAxia, and Rapid Medical. R Nogueira: Concentric Medical, ev3 Neurovascular, CoAxia, and Rapid Medical.
E-043 Image guided sympathetic blocks
Authors: Massari F , Tsai N , Rumboldt Z , Pedicelli A , Bonaldi G , Cianfoni A
Published: July 2012

Introduction/purpose

Aim of this education exhibit is to offer an overview on image guided sympathetic blocks, focusing on specific indications and techniques, through the use of Fluoroscopy and/or CT imaging guidance, at each level of blockade.

Materials and Methods

Sympathetic blocks are used for diagnostic, prognostic and therapeutic purposes for painful and other conditions associated with sympathetic system dysfunctions. Main indications for sympathetic blockade are: Complex regional pain syndrome (CRPS), phantom limb pain, central pain, hyperhydrosis, acute pancreatitis, and abdominal viscera cancer pain. Stellate ganglion blocks are utilized for painful and non-painful conditions related to sympathetic dysfunctions of head, neck and upper extremities. Thoracic sympathetic blocks are utilized for CRPS, postoperative analgesia, pain from fractured ribs, therapeutic control of hyperhydrosis of the upper limbs and torso, liver capsule pain after blunt trauma, acute postherpetic neuralgia, and premature ventricular contractions. Coeliac plexus blocks are utilized in pain due to intra-abdominal cancer, stemming from organs innervated by coeliac plexus. Lumbar sympathetic blocks are utilized for CPRS of the lower extremities, herpes zoster, amputation stump pain and inoperable peripheral vascular vasospastic diseases of the lower limb. Superior hypogastric blocks are utilized for pelvic pain, and pelvic organs cancer pain (uterus, cervix, bladder, prostate, urethra, testes and ovaries). Impar ganglion blocks are utilized in coccydynia.

Results

The sympathetic nervous system has been implicated in numerous pain syndromes including neuropathic, vascular and visceral pain. In relation to this, in order to determine the sympathetic role in the transmission of pain and to manage these algic syndromes, sympathetic ganglia are targeted for local anesthetic blocks, for diagnostic, prognostic, and therapeutic purposes, balanced in a more complex pain treatment strategy, in the treatment of CRPS and other pain conditions. Safe and precise performance of these blocks requires knowledge of the loco-regional anatomy, accurate imaging guidance, and rigorous technique. Elements of relevant fluoroscopic and cross sectional anatomy, as well as procedural technique elements are discussed and displayed.

Conclusion

This educational exhibit summarizes the indications, the anatomy and the techniques, under Fluoroscopy or CT guidance, for the sympathetic blocks.

Competing interests

None.
E-048 Flow characteristics of three toroidal aneurysms
Authors: Hui F , Piccinelli M , Passerini T , Spiotta A , Moskowitz S , Tong F , Veneziani A
Published: July 2012

Introduction

Donut-shaped, or Toroidal aneurysms are a rare angiographic morphology wherein an intraluminal thrombus forms at the center of the aneurysm sac, creating a “hole” in the flow of blood. Formation of these “cross-bars” of clot is presumably related to flow characteristics related to the shape of the aneurysm sans-thrombus.

Methods

In these computational flow dynamics (CFD) investigations, assessment of the native flow characteristics was made, as well as CFD for the lesion with the axial thrombus mathematically removed from the model to assess probable flow characteristics.

Findings and conclusion

CFD findings show flow characteristics are displayed. And discussion of further directions of analysis will be given.

Competing interests

None.

Abstract E-048 Figure 1Abstract E-048 Figure 2
E-051 Putting the “Eye” in I.V. Access—unconventional approaches in head and neck intervention
Authors: Baxter B , Mayich M , Hungerford J
Published: July 2012

Introduction/purpose

Unconventional Access techniques have been documented in the literature and have the potential to provide a complimentary platform for intervention in select cases. This limited case series illustrates two such approaches.

Materials/methods

Periprocedural clinical data and imaging was gathered around two cases requiring unconventional methods of access.

Results

A 29-year-old female with known NF-1 was found to have a large dural AVF causing significant compression of the cervical cord. In the first stage of embolization, the right vertebral artery and thyrocervical perforating vessels providing antegrade flow to the lesion were occluded using a traditional femoral approach. Access to the left vertebral artery from the same approach was precluded by an aplastic proximal segment. Access to deploy coils and onyx to the distal right vertebral artery occluding retrograde filling was achieved by direct puncture of the artery near the skull base under fluoroscopic guidance. A 67-year-old female was diagnosed with a dural cavernous-carotid fistula after presenting with proptosis and conjuctival chemosis. Embolization of perforating branches from the external carotid by femoral approach was unsuccessful in occluding flow. Access was obtained by performing a limited cut down of the upper eyelid with ultrasound-guided catheterization the superior ophthalmic vein. Embolization of the cavernous sinus with coils and onyx resulted in immediate symptom resolution.

Conclusion

In the absence of favorable access to a lesion by conventional femoral approach, unconventional access techniques may be safely employed for definitive treatment.

Competing interests

B Baxter: Stryker Neurovascular, Penumbra, EV3, Codman, Rapid Medical, Reverse Medical. M Mayich: None. J Hungerford: None.
E-053 Activated clotting time measurements are essential for monitoring effective anti-coagulation during endovascular neurosurgical procedures requiring the use of heparin
Authors: Hou S , Gounis M , Wakhloo A
Published: July 2012

Background and Purpose

Safe and effective anticoagulation plays a pivotal role in neuro-interventional procedures. Patients routinely receive heparin for prevention of intra-procedural thrombosis or thromboembolic complications. We have recently noticed time-dependent variations in intra-procedural thrombosis and thromboembolic complications during our neuro-interventional procedures. Here, we evaluate the effectiveness of our intra-procedural anticoagulation therapy.

Materials and Methods

We performed a retrospective case review, comparing the total amount of intravenous heparin administered per case, the peak activated clotting time (ACT) as measured by the i-STAT system, and number of intra-procedural thrombotic complications of 27 consecutive intracranial endovascular neurosurgical procedures requiring intra-procedural anticoagulation from July 1, 2011 through October 15, 2011 (Group 2011) compared to 40 consecutive intracranial endovascular neurosurgical procedures requiring intra-procedural anticoagulation from July 1, 2010 through December 31, 2010 (Group 2010).

Results

The mean for total heparin dose given per case for Group 2011 was 12 903 units of heparin, with a SD of 6901, while the mean for total heparin dose given per case for Group 2010 was 8463 units of heparin with a SD of 2484 (p<0.0001, t-test). The peak ACT per case for Group 2011 was 299.2 s with SD of 47.02 compared to the peak ACT per case for Group 2011 was 315.7 with SD of 39.62 (ns). There were a total of six thrombotic complications for Group 2011 vs one thrombotic complication for Group 2011 (p<0.05, Fisher Exact Test). The RR of experiencing a thrombotic complication between the two groups (2010 vs 2011) is 4.266 (95% CI 0.6873 to 26.475).

Discussion and Conclusions

When comparing Group 2011 with Group 2010, it took significantly more heparin to maintain similar peak ACT levels and there was a significant increase in the risk of developing a thrombotic complication. These findings are highly suggestive of the decreased effectiveness of intravenous heparin during the dates of July 1, 2011 through October 15, 2011 when compared to a similarly matched group of patients receiving heparin between July 1, 2010 through December 31, 2010. The total heparin dose per case for Group 2011 was not titrated to a predetermined ACT value prior to the start of the endovascular neuro-intervention, but rather a cumulative sum dose of heparin after the end of the procedure. These data give evidence that obtaining an adequate ACT level prior to the start of any endovascular neuro-interventional procedure requiring the use of heparin.

Competing interests

None.
E-056 Time from CT to groin puncture lower in patients transferred from outside hospitals compared to the local emergency room
Authors: Nogueira R , Glenn B , Belagaje S , Anderson A , Frankel M , Nahab F , Gupta R
Published: July 2012

Introduction

Patients being transferred from outside facilities are often excluded from intra-arterial therapy due to delays in transfer, evaluation and imaging. The Marcus Stroke and Neuroscience Center at Grady Memorial Hospital is a unique prototype for stroke reperfusion therapies in the future. The CT scanner and biplane angiography suite are housed in the intensive care unit. Patients being transferred from outside facilities are brought directly to the intensive care unit where imaging and reperfusion therapies can be performed rapidly. We sought to determine if there were time differences in patients evaluated in our emergency room compared to transfers from outside facilities.

Materials and Methods

A prospective database of consecutive intra-arterial therapy at the Marcus Stroke Center was reviewed. Patients treated from October 2010–January 2012 were reviewed. We assessed demographic, radiographic and clinical variables in addition to if patients were transferred from outside facilities. We assessed times from CT to groin puncture for patients evaluated in our emergency room and compared them to patients transferred from outside hospitals. Patients with anterior circulation strokes <8 h from symptom onset were assessed. Patients with posterior circulation strokes were excluded. We performed Fisher's exact testing for categorical variables and student's t-test for continuous variables.

Results

A total of 165 patients with a mean age of 66±13 years with a mean NIHSS of 19±5. A total of 109 (65%) patients were transferred from outside hospitals. Patients from outside facilities were significantly less likely to have hypertension (61% vs 81%, p<0.01) but there were no baseline differences in age, NIHSS, clot location and time from symptom onset. Patients transferred from outside facilities had significantly lower times from CT at our institution to groin puncture compared to patients from our emergency room (42±20 min vs 74±30 min, p<0.0001).

Conclusions

The presence of a biplane angiography suite in the neurological intensive care unit may help to reduce times to reperfusion in patients being transferred from an outside facility. Developing systems of care to reduce times to reperfusion will require assessment of systems of care that focus on available resources. Efficient systems to treat patients from outside hospitals may help to improve the ability to offer treatments to more patients.

Competing interests

R Nogueira: EV3, Rapid Medical, Concentric, CoAxia. B Glenn: None. S Belagaje: None. A Anderson: None. M Frankel: None. F Nahab: None. R Gupta: Concentric Medical, CoAxia, Rapid Medical, Codman Corp.
E-058 The ultimate sacrifice of a recalcitrant common carotid pseudoaneurysm after carotid endarterectomy
Authors: Nduku V , Veznedaroglu E , Liebman K
Published: July 2012

Common Carotid Artery (CCA) pseudoaneurysms are uncommon vascular lesions. They are most likely to occur as a sequelae of previous neck surgery (CEA incidence <1%), blunt or penetrating injuries to the neck, cancer with radiation necrosis, iatrogenic, mycotic and fibromuscular dysplasia than spontaneously. Formation of CCA pseudoaneurysm post CEA can occur anytime from 2 days to 22 years and is attributed to wound dehiscence, suture failure, and arterial wall breakdown resulting from infection and the quality of the graft. We report the case of a neurologically asymptomatic 75-year-old male who developed an impressive, pulsatile pseudoaneurysm of the Right CCA 1 year after having bilateral CEA. There was less deliberation in his management options for he was referred to us by his General Vascular Surgeon. Angiograms revealed a 20.3 mm × 27.8 mm RCCA pseudoaneurysm that was rendered impotent using selective catherization with stent and coil embolization. Two weeks after discharge, he returned with a ruptured RCCA pseudoaneurysm and extravasations of blood through his previous incision site (CEA). New angiograms not only confirmed the stability of the 2 week old coils and stent construct but revealed a patent flow area inferior to the coils and posterior to the stent. This was again managed endovascularly using more coiling. Complete control of the pseudoaneurysm without any hemodynamic compromise was achieved and the patient was discharged home neurologically intact with no signs of infection. After 1 week, he returned with active pulsatile recalcitrant hemorrhage. This life threatening exsanguination was controlled by sacrificing the Right CCA (Parent Artery Sacrifice) after performing a Balloon Test Occlusion. This case brings to light an uncommon pathology, the complexity of its management, endovascular vs open surgical options, and the futile but systemic attempt to spare the parent artery.

Competing interests

None.

Abstract E-058 Figure 1Abstract E-058 Figure 2
E-060 Dural arterio-venous fistula presenting with acute encephalopathy
Authors: Al Wafai A , Afshani M , Kazemi S
Published: July 2012

Background

Dural Arterio-venous fistulas (DAF) comprise 10%–15% of all intracranial vascular lesions. These are mostly acquired lesions. The DAF can be asymptomatic or they can present with nonaggressive symptoms (eg, tinnitus) or aggressive symptoms (eg, hemorrhage or neurological deficits).

Case report

We are reporting a case with DAF, who presented with acute encephalopathy. The patient is a 62-year-old male who presented with 4 days history of headache and progressive confusion. About 2 months prior to this admission, the patient was diagnosed with DVT in lower extremity and also superior and lateral sinus thrombosis. He was fully anti-coagulated and his INR on this presentation was 2. MRI of head showed multiple engorged cerebral veins. Four vessels cerebral arteriogram showed DAF with several arterial feeders from middle meningeal arteries, occipital arteries and also bilateral vertebral arteries. Partial embolization of the fistula was achieved with ONYX immediately post procedure patient's mental status improved and on last follow-up patient came back to his baseline.

Conclusion

DAF can present with acute encephalopathy due to venous hypertension.

Competing interests

None.
E-069 Restenosis after carotid artery stenting using the carotid wallstent: frequency of restenosis and effect of cilostazol in preventing restenosis
Authors: Takayama K , Taoka T , Myouchin K , Wada T , Nakagawa H , Kichikawa K , Kurokawa S
Published: July 2012

Background and Purpose

Restenosis after carotid artery stenting (CAS) is a postoperative problem, with a reported frequency around 2%–8%. However differences in stent design, procedure, and the antiplatelet agent appear affect the incidence of restenosis. We assessed the frequency of restenosis and the effect of the antiplatelet agent cilostazol (CLZ) in preventing restenosis after CAS by the standard procedure using the Carotid Wallstent (CWS).

Materials and Methods

Between May 2010 and October 2011, 62 lesions in 60 consecutive patients of CAS using the CWS were performed and all patients were followed clinically and assessed by ultrasonography, 3D-CTA or angiography at 3 and 6 months postoperatively. Restenosis was defined as ≥50% stenosis, The incidences of restenosis and differences in the incidence of restenosis by the difference in type of antiplatelet agent between the CLZ group (n=30; aspirin 100 mg and CLZ 200 mg) and the non-CLZ group (n=32; aspirin 100 mg and clopidogrel 75 mg (n=29) or ticlopidine 100 mg (n=2), 200 mg (n=1)) were retrospectively investigated. Two antiplatelet agents were given starting 1 week preoperatively until at least 3 months postoperatively.

Results

Restenosis occurred in five patients (8.3%), but all were cases of asymptomatic lesions in the follow-up period. All five patients of restenosis were in the non-CLZ group, with no cases of restenosis in the CLZ group; the difference was significant (p=0.0239).

Conclusion

The restenosis rate after CAS using CWS was 8.3%. CLZ was associated with significant inhibition of restenosis.

Competing interests

None.
E-074 Intravenous thrombolysis and endovascular therapy for acute ischemic stroke with internal carotid artery occlusion: a systematic review of clinical outcomes
Authors: Mokin M , Kass-Hout T , Kass-Hout O , Dumont T , Kan P , Snyder K , Siddiqui A , Levy E
Published: July 2012

Background and Purpose

Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with extremely poor prognosis. Best treatment approach to acute stroke in this setting is unknown. We sought to determine clinical outcomes in patients with acute ischemic stroke due to ICA occlusion treated with intravenous (IV) systemic thrombolysis or intraarterial (IA) endovascular therapy.

Methods

Using the PubMed database we searched for studies that included patients with acute ischemic stroke due to ICA occlusion who had received treatment with IV thrombolysis or IA endovascular interventions. Studies that provided data on functional outcomes beyond 30 days, mortality and symptomatic intracerebral hemorrhage (sICH) rates were included in our analysis.

Results

We identified 28 studies with a total of 385 patients in the IV thrombolysis group and 584 patients in the endovascular group. Rates of favorable outcomes and sICH were significantly higher in the endovascular group than in the IV thrombolysis-only group (33.6% vs 24.9%, p=0.004 and 11.1% vs 4.9%, p=0.001, respectively). No significant difference in mortality rates was found between the two groups (27.3% in the IV thrombolysis group vs 32.0% in the endovascular group, p=0.12).

Conclusions

According to our systematic review, endovascular treatment of acute ICA occlusion results in improved clinical outcomes. A higher rate of sICH following endovascular treatment does not result in an increased overall mortality rate. Randomized trials comparing systemic thrombolysis vs endovascular treatment are needed to determine the best treatment strategy in patients with acute ICA occlusion.

Competing interests

M Mokin: None. T Kass-Hout: Genentech. O Kass-Hout: None. T Dumont: None. P Kan: None. K Snyder: Toshiba and ev3. A Siddiqui: NINDS 1R01NS064592-01A1, University at Buffalo. Shurtleff, Inc., Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra. Codman & Shurtleff, Inc, Genentech. Hotspur, Intratech Medical, StimSox, Valor Medical. Abbott Vascular, American Association of Neurological Surgeons, Neocure Group LLC, an Emergency Medicine Conference, Abbott Vascular. E Levy: Codman & Shurtleff, Inc.,ev3/Covidien Vascular Therapies, Boston Scientific. TheraSyn Sensors, Inc. Medical Ltd., Mynx/Access Closure.