Safety and Effectiveness Analysis of Endovascular Treatment vs Standard Medication Treatment in Patients with Progressive AIS-LVO Stroke in the Ultra-late Time Window: A Propensity Score Matched Cohort Study.

BACKGROUND AND PURPOSE: The time from onset to symptom deterioration in ischemic stroke often exceeds 24 hours, and this ultra-late time window is excluded from the endovascular treatment (EVT) guideline. This study aimed to explore the safety and efficacy of EVT in progressive acute ischemic stroke with large vessel occlusion (AIS-LVO) stroke patients with onset to symptom deterioration times of 24h-7 days. METHODS: Progressive stroke patients with time window of 24h-7 days treated at our hospital over the past 6 years were retrospectively collected. Patients were categorized into EVT and standard medication treatment (SMT) group based on the treatment approach. Patients were matched using propensity score matching (PSM). Safety outcomes primarily included 3-month mortality and symptomatic intracranial hemorrhage (sICH), efficacy outcome primarily included functional independence (3-month mRS≤2). RESULTS: A total of 396 patients were included in the study, with 86(21.7%) in EVT and 310(78.3%) in SMT group. There were 140 remaining after PSM, with 70 in each group (50%). Compared to SMT group, EVT group had higher functional independence (52.9% vs 15.7%, OR=7.504, 95% CI 2.141-14.093, P<0.001) and lower 3-month mortality (14.3% vs 40.0%, OR=0.412, 95% CI 0.099-0.856, P<0.001). EVT was also associated with higher sICH (25.7% vs 5.7%, OR=9.926, 95% CI 1.874-36.547, P<0.001). CONCLUSION: For patients with progressive AIS-LVO in the ultra-late time window, EVT remains a viable treatment approach.

Infrapopliteal Surgical and Endovascular Intervention.

Infrapopliteal revascularization is generally performed for patients with chronic limb-threatening ischemia. As with revascularization in other fields, the indications for endovascular treatment (EVT) have expanded in recent years due to advances in endovascular devices and techniques. However, the optimal revascularization method must be selected based on (1) patient risk, (2) limb severity, and (3) anatomical pattern of disease. Therefore, vascular surgeons need to understand the characteristics of EVT and surgical treatment and improve their technical skills in both procedures. Here is an overview of the current methods of revascularization. (This is a translation of Jpn J Vasc Surg 2024; 33: 61-65).

Revascularization of the Femoropopliteal Artery Region.

In recent years, endovascular therapy (EVT) has come to play an important role in the revascularization of the femoropopliteal artery region; however, the number of cases that cannot be treated with EVT is increasing, and the importance of bypass surgery has been reaffirmed. We will provide an overview of the revascularization of the femoropopliteal artery region in accordance with the JCS/JSVS 2022 Guideline on the Management of Peripheral Arterial Disease. (This is a translation of Jpn J Vasc Surg 2024; 33: 57-59).

Evaluation of Thoracic Endovascular Repair for the Treatment of Type B Aortic Dissection Complicated by Malperfusion.

Objectives: This study aims to investigate the efficacy of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) complicated by malperfusion. Methods: This retrospective study included patients who underwent TEVAR for the treatment of TBAD complicated by malperfusion from June 1998 to June 2022 in four institutions. In addition to the common outcomes, including short- and medium-term mortality and morbidity, the preservation of each organ was investigated. Results: A total of 23 patients were included in this analysis. The 30-day mortality was 4% (1/23) of the patients. The overall survival rate was 87% at 1 year. The preservation rate of each organ was 33% (4/12) for the visceral organs, 85% (17/20) for the kidneys, and 100% (18/18) for the legs. Fisher's exact test showed a significant difference in the preservation rate between the viscera and the other organs (P = 0.018 vs. kidneys, P = 0.0025 vs. legs). It was shown that the survival rate of patients with visceral malperfusion was significantly lower than that of patients with non-visceral malperfusion (P = 0.006). Conclusion: In terms of mortality, TEVAR showed satisfactory results. The preservation of visceral organs was still challenging even with TEVAR and adjunctive measures.

Coil Embolization of a Ruptured Anterior Spinal Artery Aneurysm Associated with Spinal Cord Arteriovenous Malformation.

The present report describes a patient with spinal cord arteriovenous malformation (AVM) and an associated anterior spinal artery aneurysm presenting with subarachnoid hemorrhage. Diagnostic spinal angiography revealed an intramedullary AVM, located at the T10-T11 level, and a prenidal saccular aneurysm at the junction of the radiculomedullary artery and the anterior spinal axis, fed by the right T8 segmental artery. The patient underwent successful selective coil embolization of the aneurysm. Follow-up angiography 3 months postoperatively showed no recurrence of the aneurysm.

Ruptured aortic aneurysm with previous endovascular aneurysm repair in a patient with high-grade angiosarcoma.

Ruptured aortic aneurysms after endovascular repair is rare, particularly in the absence of type I or type III endoleaks. In such cases, a thorough investigation into the causes is imperative, including the consideration of an underlying malignancy. We report a case involving a 78-year-old woman who experienced abdominal aortic aneurysm rupture 4 years after aortic endograft treatment. We explanted the endograft and performed aortobi-iliac bypass. Initial aortic thrombus pathological analysis revealed atherosclerosis. However, the patient returned 4 months later with multiple lesions suggestive of metastases, and a reevaluation of the pathology slides uncovered a diagnosis of angiosarcoma.

Effectiveness and safety of detachable fibered coils as a single therapy for embolization in venous origin chronic pelvic pain.

OBJECTIVES: To investigate the effectiveness and safety of endovascular treatment by embolization with detachable fibered coils of insufficient pelvic veins, as the primary cause of Venous Origin Chronic Pelvic Pain (VOCPP). METHODS: This observational, retrospective study analyzes data from the PELVIC registry from 2014 to 2022. Sociodemographic, diagnostic, preoperative, intraoperative, and postoperative follow-up variables were reported. RESULTS: A total of 255 patients were included, with follow-up periods up to 5 years. The study's effectiveness was significant with a 60% decrease in pelvic pain at the first follow-up after treatment measured by a Visual Analogue Scale (p = 0.001). There were also decreases in the severity levels of dyspareunia (p = 0.03), dysmenorrhea (p = 0.12) and presence of Pelvic Venous Disorders symptoms in general (-43.8%; p = 0.001). No major adverse events were recorded. Only 5 patients (2%) experimented technical issues in coil implantation, all of them solved in situ. CONCLUSION: The treatment of VOCPP by embolization with detachable fibered coils has proven to be an effective and safe option for insufficient pelvic veins.

Performance assessment of the Surpass Evolve flow diverter for the treatment of intracranial aneurysms: A systematic review and meta-analysis.

BACKGROUND: The Surpass Evolve (SE) has emerged as a promising alternative treatment from the flow diverter series. The utilization of the SE has gradually increased, however, there is a scarcity of comprehensive data on the solidity of this technology in the endovascular treatment of intracranial aneurysms (IAs). This meta-analysis aimed to evaluate the safety and effectiveness of the SE flow diverter. METHODS: A systematic literature search from inception to April 2024 was conducted across five databases for studies involving IAs treated with the SE. The primary effectiveness outcome was the proportion of complete aneurysm occlusion at the final follow-up, and the primary safety outcome comprised a composite of early and delayed complications. Subgroup analyses based on aneurysm size, anatomical location, and rupture status were also conducted. RESULTS: Our analysis included nine studies with 645 patients and 722 IAs. Effectiveness outcomes revealed an overall complete aneurysm occlusion rate of 69% (95% confidence interval (CI) = 58%-78%; I2 = 72%) and a favorable aneurysm occlusion rate of 91% (95% CI = 82%-96%; I2 = 49%). Safety outcomes demonstrated an overall complications rate of 6% (95% CI = 3%-12%; I2 = 66%), with an early complications rate of 6% (95% CI = 4%-11%; I2 = 0%), and a delayed complications rate of 0% (95% CI = 0%-7%; I2 = 0%). CONCLUSIONS: Our findings suggest a favorable outcome with a high rate of complete aneurysm occlusion at the last follow-up, with acceptable rates of neurological complications. Future research efforts should focus on larger, prospective studies with standardized outcome measures to further elucidate the clinical utility of the SE flow diverter in the management of IAs.

Endovascular treatment of a large bone cement pulmonary embolism: Case report.

We report a case of endovascular treatment of bone cement embolism after percutaneous vertebroplasty. The patient underwent percutaneous vertebroplasty for acute L1 compression fracture. Two weeks later, the patient developed symptoms of pulmonary embolism. Computed tomography pulmonary angiogram confirmed the presence of a bone cement foreign body in the pulmonary artery. Endovascular treatment was performed, and the cement embolism was caught, pulled to the level of the iliac vein, and fixed with stents. At the 1-year follow-up, the patient did not have any complaints, postoperative computed tomography pulmonary angiogram showed no obvious manifestations of pulmonary embolism, and angiography showed that the bone cement was fixed in place and that the iliac veins were normal.

Limb Salvage With Continuous Intra-Arterial Infusion for Below-the-Ankle Arterial Occlusions in Acute Limb Ischemia.

A 79-year-old man presented with acute-onset coldness and severe pain in his left foot 4 hours prior. His foot (distal to the left Lisfranc joint) was pale and cold with slight motor and sensory deficits. Angiography demonstrated occlusion of the lateral plantar artery and plantar metatarsal arteries (PMAs). Angioplasty using balloons for each PMA and lateral plantar artery was conducted, but failed to achieve satisfactory blood flow. The foot condition subsequently worsened. A 22-gauge cannula was then inserted into the dorsalis pedis artery, and continuous local intra-arterial infusion of heparin, alprostadil, and nicorandil was administered. A marked reduction in the cyanotic areas of the foot was observed, with improved motor and sensory deficits post-continuous local intra-arterial infusion therapy. Follow-up angiography via the cannula on day 3 of hospitalization demonstrated significant flow improvement in the first to third PMAs. Foot salvage was achieved without tissue necrosis or amputation.

Bilateral Carotid-Cavernous Fistula Following Traumatic Fall: A Case Report.

Carotid-cavernous fistulas (CCFs) are abnormal connections between the carotid arteries and the cavernous sinus, posing significant neuro-ophthalmologic risks. This report presents a rare case of bilateral post-traumatic CCFs, focusing on clinical presentation, diagnosis, and management. Symptoms mimic conjunctivitis, causing diplopia, exophthalmos, and ophthalmoplegia. Diagnosis relied on computed tomography, magnetic resonance angiography, and digital subtraction angiography. Management involved transarterial embolization with coils, achieving successful outcomes. This highlights the importance of timely intervention and comprehensive imaging to prevent complications. Teaching point: This case report details a rare instance of bilateral post-traumatic carotid-cavernous fistulas, emphasizing clinical presentation, diagnostic evaluation, and management.

Review of current treatment modalities and clinical outcome of giant saccular aneurysms of the basilar apex.

Introduction: Giant aneurysms of the basilar apex represent formidable challenges as the high rupture rate of untreated lesions must be balanced against the technical complexity and potential morbidity of intervention. Research question: Review of treatment modalities and outcomes of patients harboring giant (>2.5 cm) basilar apex saccular aneurysms, in an effort to refine treatment decision-making. Material and methods: A systematic literature review through the PubMed and Scopus databases was performed according to the PRISMA guidelines to identify cases of giant basilar apex saccular aneurysms treated either microsurgically or endovascularly. Patients' demographics, aneurysm size, preoperative and postoperative neurologic status, angiographic and clinical outcomes as well as follow-up information were obtained. Results: Data from 32 studies fulfilling the inclusion criteria, including 49 patients (32 treated surgically and 17 endovascularly) was obtained. Mean patient age at presentation was 51.69 years, with a male-to-female ratio of 1:2. Mean maximum aneurysm diameter was 30.57 mm. A favorable outcome (mRS 0-2) was reported on 70.6% of endovascular and 56.3% of open surgical cases. Complete aneurysm occlusion was achieved in 55.6% of the open and 23.5% of the endovascular cases. Death rate was 33% for endovascular and 15.6% for open cases; the higher mortality of endovascular treatment is mainly attributed to the mass effect from continued brainstem compression after treatment. Discussion and conclusion: Higher rates of complete occlusion but higher morbidity are associated with microsurgery compared to endovascular modalities. Severe, clinically apparent brainstem mass effect may require decompression associated with microsurgery, when technically feasible.

The Current Status of Endovascular Treatment for Extracranial Vertebral Artery Stenosis in Japan: A Subanalysis of the Japanese Registry of Neuroendovascular Therapy 4.

Endovascular treatment (EVT) is a potential therapeutic option for extracranial vertebral artery (VA) stenosis; however, its efficacy or optimal procedures remain unknown. This study aimed to investigate the recent status of EVT for extracranial VA stenosis in Japan using a nationwide registry. We conducted a post hoc analysis of the Japanese Registry of Neuroendovascular Therapy 4 that enrolled patients who underwent EVT at 166 hospitals in Japan from 2015 to 2019. The outcomes of this study were as follows: procedural success indicating that the planned procedure was completed, modified Rankin Scale (mRS) score at 30 days, and procedure-related complications evaluated according to the procedure during EVT (percutaneous transluminal angioplasty vs. stenting and with or without the use of embolic protection devices [EPDs]). Of 308 eligible patients, 301 (95%) were treated for atherosclerotic stenosis, predominantly by stenting (74%). EPDs were used in 43%, primarily with the distal balloon (63%). The proportion of procedural success was 98%. Functional independence (mRS of 0-2) at 30 days was achieved in 80% of the total cohort, and there were no differences between patients treated with or without stenting or EPDs (74% vs. 82%, p = 0.12, and 80% vs. 80%, p = 0.93). Procedural complications occurred in 28 (9.1%) patients similarly in each group, with distal embolism and vessel dissection being common. In conclusion, EVT is a reasonable option for extracranial VA stenosis as a daily clinical practice. This study emphasizes the potential of EVT in managing extracranial VA stenosis and the need for further research to refine treatment strategies.

Characteristics of middle cerebral artery aneurysms treated endovascularly in a clip-favored institution.

BACKGROUND: The emergence of flow disruptors has brought a dynamic transition in the selection of treatment for middle cerebral artery (MCA) aneurysms, and the number of MCA aneurysms clipped is acceleratingly decreasing. Still, retreatment after endovascular treatment is still a dilemma, which may necessitate surgical clipping. It is all the more important to elucidate characteristics of MCA aneurysms that make clipping unfavorable. Thus, the practical characteristics of MCA aneurysms treated endovascularly in a clip-favored institution before the usage of flow disruption devices were investigated. METHODS: This is a retrospective, single-center observational study. The clinical and imaging characteristics of treated MCA aneurysms from January 2012 to May 2022 were analyzed. RESULTS: A total of 83 aneurysms were included; 70 aneurysms (84%) were clipped, and 13 (16%) were treated endovascularly. Eighteen aneurysms (22%) were ruptured (clipping, 12; endovascular, 6). The reasons for an endovascular treatment were as follows: distal (3); subacutely ruptured with burdens of spasm (2); multiple aneurysms (6: another clipped in 3, coiled in 1, and conservatively managed in 2); no access to the operating room due to COVID-19 (1); and retreatment after coiling (1). Endovascular group aneurysms were smaller (maximum diameter 5.2 vs 7.3 mm, p < 0.01, as well as dome, neck, and height) without differences in the dome/neck and aspect (height/neck) ratios. In a subgroup analysis of 78 MCA bifurcation aneurysms, the endovascular group was still smaller (dome 4.4 vs 5.8 mm, p = 0.025; neck 2.8 vs 3.9, p = 0.03). CONCLUSION: In a limited series from a clip-favored institution before the flow disruption era, factors guided to endovascular treatments on MCA aneurysms were rather anatomical and clinical factors such as distal location, subacutely ruptured, multiple, or retreatment after coiling, than morphological factors such as dome/neck and aspect ratios albeit smaller size.

Venous obstruction of the upper extremity caused by subclavian vein valve hypertrophy.

This case report detailed a rare case of upper limb venous outflow obstruction due to primary subclavian vein valve hypertrophy in a 26-year-old male. Misdiagnosed initially, the condition was identified through advanced Doppler ultrasound and CT venography. Endovascular treatment using Wallstent stents effectively resolved the obstruction, preserving collateral venous circulations. This case highlights the importance of combined colour doppler ultrasonography for diagnosing unusual venous obstructions and demonstrates the potential of endovascular treatments in managing rare venous conditions.

Initial Experience with the New DERIVO® Mini Embolisation Device for the Treatment of Intracranial Aneurysms.

The aim of this study is to present the outcomes of cerebral aneurysm treatment with the DERIVO® mini Embolisation Device (DMD), which is compatible with microcatheters with 0.021-inch inner diameters. Consecutive patients treated with DMD were identified retrospectively. Patient and aneurysm characteristics, procedural findings, clinical outcomes and follow-up imaging results were evaluated. A total of 44 target aneurysms in 30 patients were treated with DMD. The mean age of the patients was 49.9 (range, 4-77 years). Four patients with five aneurysms presented with acute subarachnoid hemorrhage. The mean aneurysm size was 6.8 mm (range, 1.5-22 mm). In 29 (65.9%) aneurysms, adjunctive devices were used for endovascular treatment. The overall mortality rate was 3.3% and procedure-related mortality was 0%. Overall neurologic morbidity was 6.6% and none of the patients had a permanent sequela secondary to the procedure. The mean clinical follow-up period was 20.9 months (range, 3 days-46 months) and the mean DSA follow-up period was 10.9 months. A total of 37 (84.1%) aneurysms demonstrated total occlusion (Raymond-Roy [RR 1]); 3 (6.8%) aneurysms had a neck remnant or infundibular filling at the origin of the jailed side branch (RR 2), 4 (9.1%) aneurysms had residual aneurysm filling (RR 3). For those aneurysms treated with bare DMD, the total occlusion rate was 73.3% at a mean follow-up of 16.1 months. In this initial clinical single-center experience, DMD had a good safety profile and efficacy comparable with the currently used flow diverters.

Some minutes matter more: Groin-to-recanalization is the main time-related predictor of outcome in acute ischemic stroke.

INTRODUCTION: Endovascular thrombectomy (EVT) is the standard of care for selected patients with acute ischemic stroke (AIS) and large vessel occlusion (LVO), associated with intravenous thrombolysis, when indicated. While many studies focused on pre-hospital and in-hospital pathways, only few analyzed the relationship between groin-to-recanalization (GTR) time and functional outcome. AIM: To explore whether GTR time is an independent predictor of outcome in patients undergoing EVT. METHODS: All patients with anterior circulation stroke treated with EVT at a high-volume center from January 2021 to December 2023 were included. The cohort was divided into two groups according to GTR time shorter or longer than 30 min. Regression analysis assessed the association between GTR time and 3-month good outcome, defined as modified Rankin Scale 0-2. RESULTS: The study included 419 patients. The groups had similar baseline characteristics and similar onset to recanalization (OTR) time. Regression analysis showed shorter GTR time is an independent predictor of favorable outcome (OR 2.49 [95% CI 1.26-4.94]). Age, baseline NIHSS, ASPECT score and bridging IVT were also found to be independently associated with outcome. DISCUSSION AND CONCLUSIONS: Our study showed GTR time is an independent predictor of good outcome in patients undergoing EVT with similar OTR time, emphasizing procedural time as a key prognostic factor, even greater than other well-known pre-hospital and in-hospital time-dependent variables. These findings may raise the issue of developing alternative approaches or early "rescue" strategies for complicated procedures.

Venous recanalisation in the setting of post-thrombotic syndrome: An expert consensus from the French Society of Vascular Medicine (SFMV) and the French Society of Cardiovascular Imaging and Interventional Radiology (SFICV).

Several aspects of the management of post-thrombotic syndrome (PTS) are still a matter of debate, or not yet addressed in international guidelines. The objective of this expert consensus from the French Society of Vascular Medicine (SFMV) and the French Society of Cardiovascular Imaging (SFICV) was to define the main elements of diagnosis and treatment of this syndrome, and to develop a proposal for its preoperative, procedural and follow-up management. In this consensus, the following issues were addressed: clinical and ultrasound diagnosis; pre-procedural workup; indications and contraindications to venous recanalisation; procedures; clinical and duplex ultrasound reports; follow-up; long-term treatment; management of great saphenous vein incompetency; anticoagulant and antiplatelet therapy after venous stenting.

StentRetriever- aspiration (SRa) vs direct aspiration (DA) in the treatment of acute M2 segment occlusion of middle cerebral artery: A single center randomized prospective study.

Decision making and patient selection for isolated occlusion of the M2 segment of the middle cerebral artery is challenging, with the efficacy of treatment for such distal occlusions still controversial in recent studies, as occlusion in such small and thin vessels tends to manifest with less severe symptoms initially and hold higher surgical risks. It is even less clear which endovascular technique is more effective for this type of occlusion, with the choice usually left to the radiologist's preference. We conducted a controlled prospective study of consecutive patients presenting to Novara Hospital with an acute M2 occlusion diagnosed at the AngioCt and, following a predetermined randomization, we divided them into two treatment arms with either stent retriever aspiration (SRa) or direct aspiration (DA). All patients were examined on admission, at discharge and after 3 months, and clinical data as well as mRS and NIHSS scale scores were recorded. Our primary aim was to evaluate the difference in recanalization rate in the two groups by comparing the angiographic eTICI obtained with the two techniques. We then investigated whether there were differences in clinical outcomes and complications. Our data confirm a good recanalization rate with an eTICI ≥ 2b in 76.19% of patients in the cohort. An overall good outcome was achieved in 57% of patients as ∆NIHSS and in 50.79% of patients considering mRS. We found no statistically significant difference in recanalization rate nor higher complication rate in either the SRa or DA group. Both techniques are safe, effective and can be considered equally.

The prognostic impact of malnutrition on the outcomes of patients with vertebrobasilar artery occlusion following endovascular treatment.

BACKGROUND AND PURPOSE: Malnutrition is associated with poor outcomes in different diseases. Our aim was to investigate whether measures of malnutrition could be used to predict 90-day outcomes in patients with vertebrobasilar artery occlusion (VBAO) undergoing endovascular treatment (EVT). METHODS: We retrospectively analyzed patients with VBAO who received EVT at three comprehensive stroke centers. Malnutrition was assessed using the controlling nutritional status (CONUT) score, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI). Primary outcome was good functional outcome defined as modified Rankin Scale (mRS) 0-3 measured at 90 days. RESULTS: A total of 285 patients were enrolled, of which 260 (91.22 %) met the requirements. According to the CONUT, GNRI, and PNI scores, the proportions of patients classified as moderately or severely malnourished were 7.3 %, 3.08 %, and 35 %, respectively. In the multivariate regression model after adjusting for potential confounders, malnutrition (severe risk versus normal nutritional status) was significantly associated with an increased risk of poor prognosis for CONUT scores (adjusted odds ratio [OR]14.91, 95 %CI, 1.69 - 131.71; P = 0.015), GNRI scores (adjusted [OR] 10.67, 1.17 - 96.93; P = 0.036) and PNI scores (adjusted [OR] 4.61, 2.28 - 9.31; P < 0.001). Similar results were obtained when malnutrition scores were analyzed as continuous variables. Adding the 3 malnutrition measures to the risk reclassification that included traditional risk factors significantly improved the predictive value of 3-month poor prognosis. CONCLUSIONS: Our study showed that malnutrition may be associated with poor prognosis within 3 months of EVT in patients with VBAO.