bluuebunny/crossref_metadata_2025_split huggingface dataset:
E-025 Transvenous embolization of cavernous carotid fistulas facilitated by a distal access catheter
Authors: Haithcock J , Toth G , Pride G 
Published: December 2010

Introduction and purposeAlthough transvenous embolization of indirect carotid cavernous fistulas (iCCFs) represents an effective treatment strategy, venous navigation related limitations can prevent access to the entire fistulous site, decreasing the probability of definitive occlusion. In such cases, more invasive access to the involved vein, such as open surgical exposure, direct puncture of the superior ophthalmic vein or direct access to the anterior portion of the cavernous sinus may be needed to achieve a definitive cure. We describe two cases in which a coaxial technique using a commercially available distal access catheter facilitated venous navigation from the common femoral vein, enabling definitive obliteration of the iCCF. Our purpose includes reporting of these cases, discussion of endovascular strategies and a review of the various venous routes of access to the cavernous sinus.Materials and methodsWe reviewed all recent endovascular procedures performed at our institution to identify two cases of iCCF in which a coaxial access technique using a commercially available distal access catheter was used to facilitate treatment. The procedural notes, hospital charts and imaging studies were reviewed to identify potential novel procedural details or problems related to this technique. Additionally, we reviewed the current medical literature related to endovascular iCCF embolization in order to complement our summary review of the various venous approaches employed for iCCF treatment.ResultsThe coaxial technique using a distal access catheter to achieve fistula access from the common femoral vein facilitated complete iCCF obliteration in both of our cases, without any added periprocedural morbidity. The technique was straightforward, easily applied and greatly simplified transvenous embolization of the iCCF in both cases.ConclusionThe distal access catheter was introduced as an adjunct device for mechanical thrombectomy procedures using the Merci embolectomy system by providing microcatheter support during clot retrieval and improved stability in tortuous arterial anatomy. Similarly, successful endovascular treatment of iCCFs from a transvenous approach also requires navigation through tortuous venous anatomy and enhanced microcatheter stability in order to achieve successful embolization of the fistula. A distal access catheter was used in two patients with iCCFs treated via a transvenous endovascular approach which greatly facilitated complete obliteration of the fistula in both cases. The use of a distal access catheter in mechanical thrombectomy procedures is well documented, and given the ease of use and compatibility with the various guiding catheters and microcatheters currently available, the distal access catheter will likely have an increasing role in other intracranial neurointerventional procedures.Abstract E-025 Figure 1
E-027 Final results of a multicenter, prospective, long term coil embolization study
Authors: Paulsen R 
Published: December 2010

PurposeTo design and set up an electronic database with longitudinal information on the use of bare platinum coils for the endovascular occlusion of cerebral aneurysms. We report the final analysis of the data.Materials and methodsFrom 1 May 2004 to 10 July 2007, a global registry was conducted at 36 centers in the USA, Europe and Latin America. 303 patients were enrolled of whom 299 patients were treated with bare detachable platinum coils (mostly Trufill DCS Orbit coils) of various sizes, shapes and grades of softness. Acute as well as long term anatomical and clinical data were collected. Logistic regression analysis will be used to examine the association of selected patient characteristics to outcomes of recanalization, retreatment and stability of occlusion.Results313 aneurysms, ruptured or unruptured, were treated in the 299 patients. Follow-up data were available on 185 patients (including 10 reports of deaths); 32 patients returned for more than one visit; 140 (76%) had 3–6 months of follow-up, 63 (34%) had 1 year of follow-up and five (3%) had 2 years of follow-up.This abstract reviews the status of 185 patients with follow-up data available at this time. Immediately postprocedure, the treating physicians reported achieving the desired level of occlusion in 167 (85%) of the treated and followed aneurysms: 114 (58%) aneurysms were completely obliterated, 40 (20%) residual neck, 23 (12%) residual aneurysm and 19 (10%) dog ear. Of 174 aneurysms with angiographic follow-up, 137 (79%) remained stable or improved, nine (5%) showed aneurysm regrowth, 26 (15%) compaction and two (1%) had migrated. At 3–6 months, 14 of the 174 (8%) aneurysms were re-treated.ConclusionThese results confirm previous outcomes data of endovascular occlusion of cerebral aneurysms with Trufill DCS Orbit complex shaped detachable platinum coils. Complications related to the device were rare.
E-028 Stenting and angioplasty of a symptomatic long segment extracranial vertebral artery occlusion
Authors: Sivapatham T , Hussain M , Spiotta A , Gupta R 
Published: December 2010

IntroductionWe report a case of successful revascularization of a symptomatic long segment extracranial vertebral artery occlusion using stenting and angioplasty. A 55-year-old man with a history of tobacco abuse, hypertension and hyperlipidemia presented with dysarthria and diplopia that occurred 3 weeks earlier. The patient was noted to have bilateral vertebral artery occlusions on CT angiography and acute infarcts involving the posterior circulation on MRI. He was placed on dual antiplatelet therapy with aspirin 325 mg daily and clopidogrel 75 mg daily along with a lipid lowering agent. The patient had recurrent symptoms despite medical therapy. He was referred to our institution for further management.Materials and methodsCerebral angiogram revealed a total occlusion of the left vertebral artery and a long segment occlusion of the extracranial right vertebral artery that reconstituted via muscular branches and thyrocervical branches. The intracranial posterior circulation remained patent due to these collaterals. No posterior communicating arteries were present. After a detailed discussion regarding surgical and endovascular options, we proceeded with the endovascular approach.The patient was placed under general anesthesia. A platelet aggregation panel prior to the procedure confirmed adequate platelet inhibition for both aspirin and clopidogrel. Intravenous heparin was administered to maintain an activated clotting time of 250–300 s throughout the procedure. A femoral artery approach was used and a 5 F diagnostic catheter was exchanged for a 6 F 90 cm Cook shuttle sheath that was positioned in the right subclavian artery for support. A 6 F Envoy guide catheter (100 cm length) was coaxially placed through the shuttle sheath into the stump of the vertebral artery.A Rapid Transit microcatheter and 0.014 in Synchro-2 microwire were initially used to attempt navigation across the occluded segment but were unsuccessful. The wire was replaced with a 0.018 in V-18 microwire and we were able to navigate across the occlusion with this wire/catheter combination. The catheter was removed over a 300 cm Transend floppy exchange wire and a total of five drug eluting, balloon-mounted Xience V stents were deployed in a telescoping fashion from the mid-cervical vertebral artery to the vertebral artery origin.ResultsPost-stent angiography demonstrated good antegrade flow through the cervical vertebral artery. The patient recovered from anesthesia with no new neurologic deficits.ConclusionRevascularization of a long segment total occlusion of the extracranial vertebral artery can be performed safely using endovascular techniques in symptomatic patients.Abstract E-028 Figure 1
E-003 Initial experience with a ‘timeout’ designed for neuroendovascular procedures
Authors: Wells K , Kapadia S , Cantrell B , Keigher K , Lopes D , Chen M 
Published: December 2010

IntroductionMorbidity and mortality as a result of medical errors has become a significant health problem. As part of a national patient safety goal initiative, almost all medical centers have adopted measures to decrease the incidence of medical errors. In order to improve communication among members of the surgical team, a preoperative checklist is done prior to initiating any procedure (time out). The neuroendovascular patient undergoing an intervention such as cerebral aneurysm coiling and/or stenting, arteriovenous malformation embolization and carotid stenting presents unique challenges compared with body interventions or open neurosurgery cases. Some of these challenges include assessment of patient kidney function, contrast allergy, femoral/pedal pulses, need for ASA/Plavix and humanitarian device exemption (HDE) consents. The purpose of this study was to develop a ‘time out’ customized to neuroendovascular patients and test it in a clinical setting.Materials and methodsWe listed the most important safety factors involving neuroendovascular interventions and compared them to the standard open surgery ‘time out’ checklist. A specific neuroendovascular checklist was developed. We then in-serviced the staff of the neuro-angio suite which included six registered nurses, four radiology technologists and two endovascular surgeons to institute the preoperative checklist. The following is an abbreviated form of the neuroendovascular time out we implemented: What patient do we have? What procedure are we doing? Do we need any HDE/special consents (Enterprise, Neuroform, Wingspan, Research)? What is the assessment of access site and marking? Is the patient positioned correctly? Are there any precautions based on status or meds? Are ASA and Plavix required for the procedure; or other special medications? Are irrigation fluids required and available? Do we require any special implants, equipment, films? If so are they available? Are any antibiotics required? Is DVT prophylaxis indicated? After 3 months of clinical application of the neuroendovascular time out at RUSH University, the team was asked to respond to a self-assessment questionnaire.ResultsThe neuroendovascular time out was applied in 152 cases over 3 months. In all cases the time out was completed before the procedure initiated. The answers to each time out were documented and incorporated to the patient's electronic medical record.The answers from the self-assessment questionnaire were obtained from all the participating members of the endovascular team. The results revealed great acceptance to the concept of time out and 12/12 questionnaires agreed that the customization was more relevant to neuroendovascular patients. There was also unanimous opinion that the neuroendovascular time out has increased safety for our patients undergoing procedures.ConclusionThe neuroendovascular time out is more relevant to cerebrovascular patients and proved to be valuable in a clinical setting.
E-036 Hemodynamic stability during carotid artery stenting under general anesthesia in elderly patients with a high grade carotid artery stenosis
Authors: Cho C , Park H 
Published: December 2010

Purpose of studyDuring carotid artery stenting (CAS) under local anesthesia, hemodynamic instability (hypotension, bradycardia, etc) has been reported to occur. Hemodynamic instability during CAS under local anesthesia, especially in elderly patients, may be a risk factor for complications.We evaluate the hemodynamic stability during CAS under general anesthesia in elderly patients with a high grade carotid artery stenosis.Methods15 CAS procedures were performed under general anesthesia using sevoflurane and nitrous oxide in oxygen in in 15 patients aged 65 years or older between November 2007 and February 2009. All CAS procedures were performed for high grade stenoses (>70% in NASCET criteria). Nine procedures were performed for symptomatic stenoses. Degree of systolic blood pressure change, hypotension and bradycardia during CAS were assessed.ResultsMean age of patients was 69±3.2 years. Mean degrees of stenosis before and after CAS was 75.8±7.5% and 25.9±9.8%, respectively. No hypotension (systolic blood pressure <80 mm Hg) occurred during procedures, and transient bradycardia (heart rate <50/min) occurred in one patient (0.6%) during the procedures. Mean systolic blood pressure change was 35±11.9 mm Hg. No procedure was complicated by stroke during or after CAS.ConclusionGeneral anesthesia using sevoflurane and nitrous oxide in oxygen depressed baroreceptor reflex sensitivity, induced hemodynamic stability during CAS and may decrease the rate of occurrence of complications in elderly patients with a high grade carotid artery stenosis.
E-037 Endovascular treatment of traumatic pediatric posterior circulation pseudoaneurysms
Authors: Farid H , Tatum J , Halbach V , Higashida R , Dowd C 
Published: December 2010

Introduction and purposeTraumatic intracranial aneurysms are rare and represent fewer than 1% of all intracranial aneurysms. They may develop as the result of blunt or penetrating head trauma and are associated with a significant mortality of up to 50%. Traumatic aneurysms typically involve the anterior circulation or the internal carotid artery at the level of the skull base. They rarely involve the posterior circulation. We present three pediatric patients with traumatic aneurysms in the posterior circulation and describe their clinical presentation, angiographic findings and clinical outcome after being treated by endovascular technique.Materials and methodsWe retrospectively reviewed the angiographic and clinical findings in three pediatric patients, aged 12 years and younger, with traumatic pseudoaneurysms occurring in the posterior circulation in a variety of locations: one in the basilar artery, one in the posterior cerebral artery and one in the superior cerebellar artery.ResultsThree patients with three posterior circulation pseudoaneurysms (two male patients and one female patient; aged 3–12 years) were admitted during the past 2 years. All three patients underwent endovascular coil embolization. No complications were noted from these procedures. All patients improved clinically after treatment.ConclusionsContemporary endovascular techniques can be used effectively to treat posterior circulation pseudoaneurysms in the pediatric population. Treatment efficacy may be improved if there are bony confines around the aneurysm or if therapy takes place in the subacute period, when the wall of the pseudoaneurysm has matured and stabilized.
E-038 Utility of Dyna CT in the evaluation and management of cranial and skull base arteriovenous fistulas
Authors: Gandhi D , Huang J , Gomez J , Kathuria S 
Published: December 2010

IntroductionIntracranial dural arteriovenous fistulas (dAVFs) are comprised of pathologic, dural based shunts and account for 10–15% of all intracranial arteriovenous malformations. These lesions have complex anatomy that is best studied with conventional digital subtraction angiography (DSA). Conventional DSA is however limited by its planar imaging nature. A more detailed analysis of these lesions is now possible with cone beam CT. We present our initial experience with 10 patients of dAVFs studied with C arm CT.MethodsThis study includes 10 patients with intracranial and skull base dAVFs that were evaluated with conventional DSA and a C arm CT (Dyna CT) between January 2009 and February 2010 by one of the authors (DG). The DSA evaluation included selected catheter angiograms of bilateral common, internal, external carotid and vertebral arteries. Additional Dyna CT evaluation was accomplished while injecting diluted contrast into the dominant feeding artery. MPRs were performed by using an external postprocessing workstation (syngoXWorkplace; Siemens Medical Solutions) to produce section thickness of 0.2–0.5 mm. This study is a retrospective review of patient charts, imaging studies and DSA/C arm CT evaluations.ResultsC arm CT was successfully performed on all patients and provided excellent quality images. The anatomic understanding of the osteodural network, location of arteriovenous shunt and venous compartment was aided by Dyna CT and significantly added to the understanding of these lesions. In addition, there were additional findings noted on Dyna CT that had significant impact on management of four of 10 patients. The final management included endovascular treatment exclusively in 5/10, combination of embolization and surgery in 1/10 and embolization followed by gamma knife in 1/10. Three of 10 patients are being managed conservatively in view of Borden type 1 fistulae that were minimally symptomatic.ConclusionC arm CT is complementary to DSA in the evaluation of cranial and skull base dAVFs. In many patients, Dyna CT provides information that is difficult to obtain from conventional DSA. In our initial experience, Dyna CT had a significant impact in the management of these lesions.
E-004 Cranial dural arteriovenous fistulas: asymptomatic cortical venous drainage portends less aggressive clinical course
Authors: Strom R , Botros J , Refai D , Moran C , Cross D , Grubb R , Chicoine M , Rich K , Dacey R , Zipfel G , Derdeyn C 
Published: December 2010

ObjectiveCranial dural arteriovenous fistulas (dAVFs) with cortical venous drainage (CVD) (Borden type 2 and 3) are reported to carry a 15% annual risk of intracranial hemorrhage (ICH) or non-hemorrhagic neurological deficit (NHND). The purpose of this study is to compare the clinical course of type 2 and 3 dAVFs that present with ICH or NHND versus those that do not.Methods28 patients with type 2 or 3 dAVFs were retrospectively evaluated. CVD was classified as asymptomatic (aCVD) if patients presented incidentally or with pulsatile tinnitus or orbital phenomena. CVD was classified as symptomatic (sCVD) if patients presented with ICH or NHND. Occurrence of new ICH or new or worsening NHND between diagnosis and disconnection of CVD or last follow-up (if not disconnected) was noted. Overall frequency of events was compared using Fisher's exact test. Cumulative event free survival was compared using Kaplan–Meier analysis with log rank testing.ResultsOf 17 patients with aCVD, one (5.9%) developed ICH and none experienced NHND or death during the mean 4.1 years of follow-up. Of 11 patients with sCVD, two (18.2%) developed ICH and three (27.3%) suffered new or worsened NHND over the mean 2.4 years of follow-up. One of these patients subsequently died. Overall frequency of ICH or NHND was significantly lower in patients with aCVD versus sCVD (p=0.022). Respective annual event rates were 1.4% versus 19.0%. aCVD patients had significantly higher cumulative event free survival (p=0.0016).ConclusionCranial dAVFs with aCVD may have a less aggressive clinical course than those with sCVD.
E-041 Combined endovascular embolization and surgical resection of a massive lumbosacral arteriovenous malformation in a patient with Cobb syndrome
Authors: Spiotta A , Hussain M , Sivapatham T , Masaryk T , Krishnaney A 
Published: December 2010

Objective and importanceCobb syndrome is a rare condition that includes a cutaneous nevus with an associated spinal vascular lesion at the same dermatome. We present a challenging case of a progressively symptomatic massive lumbosacral arteriovenous malformations (AVM) in a patient with Cobb's syndrome requiring a multimodality approach, including staged preoperative transarterial and transvenous endovascular embolization followed by surgical excision and wound reconstruction.Clinical presentationThe patient is a 25-year-old man with a massive lumbosacral AVM with symptoms of congestive heart failure. Angiography demonstrated arterial feeders predominantly from the internal iliac, median sacral and lumbar segmental arteries.InterventionThe patient underwent staged transarterial and transvenous endovascular embolization resulting in 90% reduction in the AVM size, followed by surgical resection of the lesion. The patient made an excellent recovery with improvement in his symptoms of congestive heart failure.ConclusionThe treatment algorithm for massive AVMs must be individualized. A combination of staged embolization and subsequent surgery may be required to obtain a good result. Through this carefully planned multidisciplinary approach, a previously incurable lesion in this patient with Cobb syndrome was able to be treated successfully.Abstract E-041 Figure 1
E-042 Incidence of very small ruptured aneurysms (<3 mm) in the stroke belt: a single center experience and outcome analysis
Authors: Turner R , Brothers M , Chaudry I , Turk A 
Published: December 2010

IntroductionVery small aneurysms (<3 mm) have a low rate of spontaneous rupture, however when treatment is warranted, pose an increased risk of procedural complications, specifically intraprocedural rupture. Endovascular treatment of these aneurysms is controversial given the high complication rate, particularly intraprocedural rupture. However, there are patients who are better suited to endovascular occlusion due to clinical grade or comorbidities. We analyzed this series of patients to evaluate procedure safety and acute outcomes using this newer coil technology.MethodsThe MUSC endovascular registry is a prospective database with predefined parameters which tracks all diagnostic and endovascular interventions. A database query was performed to obtain all aneurysms measuring <3 mm. Immediate occlusion rates and procedural complications were evaluated for safety and efficacy. The most current clinical status of patients was also evaluated for outcome analysis.Results15 patients with 16 aneurysms underwent coil embolization between August 2009 and February 2010, representing 17.2% of all aneurysms coiled during that period. 11 of the 16 aneurysms (69%) were ruptured, four (25%) were unruptured aneurysms in patients with a history of subarachnoid hemorrhage (SAH) and a previously treated ruptured aneurysm and one patient was unruptured with a strong family history of SAH. Mean length of the largest diameter was 2.7 mm (range 2–3 mm). All but one aneurysm achieved complete occlusion acutely, and high packing densities were obtained in all aneurysms. Eight aneurysms (seven ruptured) were treated with a balloon assist technique and were not associated with any adverse events. Four aneurysms (one ruptured) were stent assisted, with two of the procedures (both unruptured) were complicated by intraprocedural rupture. Both patients were discharged from the hospital within 4 days of the procedure with no clinical deficits and a modified Rankin scale (mRS) score of 0. Four aneurysms (three ruptured) were treated without adjunctive devices and one patient (ruptured) had an intraprocedural rupture without clinical consequence and was discharge on hospital day 14. Overall, 12 patients had an mRS score of 0 and one patient a score of 1. One patient has an mRS score of 4 but presented with a Hunt and Hess score of 5 with minimal improvement. One patient is currently completing his acute treatment.ConclusionsVery small aneurysms account for a significant number of aneurysms treated at our institution. Complete occlusion is achievable in a large percentage of these aneurysms but they are associated with a higher procedural complication rate. In patients with ruptured (and unruptured) aneurysms, clinical outcomes were very good. Long term outcomes and follow-up are forthcoming.