Unstable Spinal Fracture With Arteria Lusoria: Management to Mitigate Aortic Risks.

Aortic injuries associated with unstable spinal fractures are a rare but serious condition, with high mortality. Rapid and multidisciplinary management is crucial to prevent fatal complications. We report the case of a female patient who, following a road traffic accident, presented with a displaced fracture of the fourth dorsal vertebrae (D4), with a detached anterior fragment adjacent to the posterior aspect of the aortic arch and the origin of the arteria lusoria. The multidisciplinary discussion concluded that surgery without an aortic prosthesis is associated with a major hemorrhagic risk due to aortic injury during spinal fixation manipulations, and surgery with a prosthesis is associated with immediate risks of ischemic cerebrovascular accident, gas embolism, and upper limb ischemia. We opted to prepare the patient for spinal stabilization surgery after placing the aortic prosthesis type: Zenith Alpha ZTA-PT-30-26-108 thoracic prosthesis (Cook Medical, Bloomington, Indiana, US). Our team's therapeutic approach is being discussed given the rarity of cases in the literature and the patient's anatomical characteristics. Surgical management in these situations must repair the unstable fracture while avoiding the aggravation of an existing or potential aortic injury. The aortic lesion can be treated first, before spinal fixation, either with open surgery, which carries a high risk of severe complications, or thoracic endovascular repair (TEVAR), which allows the prevention of the potential aortic injury or repair of the existing aortic injury while minimizing the side effects of open surgery. However, endovascular surgery may have limitations due to individual vascular anatomy, as in our patient's case, which can prevent optimal endograft positioning and lead to risks such as endoleak, ischemia, infection, or thrombosis, necessitating periodic radiological follow-up. Endovascular repair is a new paradigm that has improved clinical outcomes for these patients by securing the vascular injury first before spinal surgery. Teamwork and multidisciplinary discussion ensure optimal safety, minimizing the side effects of these lesions, which can be fatal at any time during management.

Pulmonary Artery Endograft Implantation Using a Parallel Stent Grafting Technique to Enable the Treatment of a Bronchial Anastomosis Complication After Lung Transplantation.

BACKGROUND: Bronchial stenosis associated with bronchial anastomosis dehiscence after lung transplantation is a catastrophic complication following lung transplantation with a paucity of therapeutic solutions. PURPOSE: To describe an adaptation of the parallel stent grafting technique in the pulmonary arterial territory to treat this challenging situation. RESEARCH DESIGN: This is a case report of a 52-year-old patient who presented bronchus stenosis and bronchial anastomosis dehiscence after lung transplantion. Bronchial stenting and lung retransplantation were contraindicated. Therefore, an endovascular approach using pulmonary artery endograft placement to prevent bleeding during repeated right bronchial balloon dilation was propposed. The technique consists of the deployment of an aortic extender endoprosthesis in the right main pulmonary artery and a balloon expandable stent in the upper lobe pulmonary artery (using a parallel graft configuration) through the common femoral and right internal jugular veins, respectively. Intraoperative transesophageal echocardiogram and one-lung ventilatory ventilation are needed. RESULTS: The patient underwent a new bronchoscopy 16 days after the procedure, that showed epithelization at the previous eroded zone, enabling bronchocopic balloon dialtion to be safely performed. A post-operative contrast-enhanced CT scan revealed an adequate positioning of the stent grafts. Despite all eforts, the patient succumbed to ventilator associated pneumonia on postoperative day 108. DATA ANALYSIS: The technique's advantages include its feasibility even in situations in which other techniques may be contraindicated and its potential use in emergencies. Its limitations include the need for experienced interventionists to perform it, and the potential risk of acute tricuspid regurgitation. CONCLUSION: This study illustrates the early feasibility of the parallel stent grafting technique applied to the pulmonary artery territory. However, it's safety profile regarding infectious risk was not demontrated.

Sex and outcomes after stenting and endarterectomy in asymptomatic severe carotid stenosis patients.

OBJECTIVES: To determine if sex was an effect modifier in a pooled analysis of asymptomatic patients from CREST and ACT I. MATERIALS AND METHODS: We analyzed data from 2544 patients aged <80 with ≥70 % asymptomatic carotid stenosis randomized to CAS or CEA (nCREST = 1091; nACT-1 = 1453). The pre-specified primary endpoint in both trials was any stroke, myocardial infarction or death during the peri-procedural period, or ipsilateral stroke within 4 years of randomization. The secondary endpoint was any stroke or death during the peri-procedural period, or ipsilateral stroke within 4 years of randomization. RESULTS: There was no significant difference in the frequency of events for men or women between CAS and CEA for the primary or secondary endpoints. When assessing for an interaction of sex and risks between procedures, the treatment-by-sex interaction was not significant for either primary or secondary endpoints in the four-year period or the peri-procedural period. However, women had significantly fewer post-procedural events (ipsilateral stroke) with CAS than CEA (HR = 0.33, 95 % CI: 0.09-1.18) compared to men (HR = 2.09, 95 % CI: 0.78-5.61), p = 0.02 for interaction. CONCLUSIONS: In this large, pooled analysis of asymptomatic patients comparing CAS to CEA, sex did not act as an effect modifier of treatment differences in the four-year primary stroke-MI-or-death endpoint or the secondary stroke-or-death endpoint. However, during the post-procedural period men treated with CAS were at higher risk than their female counterparts.

Total endovascular repair of a common femoral artery aneurysm with a bifurcated endograft through a single ipsilateral approach.

Aneurysms of the common femoral and profunda femoris arteries are rare. Open surgical repair is the treatment of choice, even though hybrid and total endovascular repair with stent graft placement are reported in the literature. We describe a case of a successful total endovascular repair of a common femoral aneurysm extending to the profunda femoris with a bifurcated abdominal endograft placed in the common femoral artery with distal landing in profunda femoris and superficial femoral artery to preserve flow in both arteries. Endovascular repair of common femoral artery aneurysms with bifurcated endografts is a feasible alternative in complex anatomies.

Saphenous Vein Graft Pseudoaneurysm Treated With Covered Stenting.

Saphenous vein graft (SVG) pseudoaneurysms are an infrequent, but life-threatening complication of coronary artery bypass grafting (CABG) surgery if left untreated. Here, we discuss the case of a 77-year-old patient, with a prior history of CABG and transcatheter aortic valve implantation (TAVI), who was incidentally found on computed tomography angiography (CTA) to have a pseudoaneurysm of his SVG with an initial chief complaint of dizziness. Despite increasing reports of SVG pseudoaneurysm, there is no consensus on definitive treatment. Due to the high mortality risk of this patient with surgical intervention, a minimally invasive percutaneous coronary intervention was performed. The patient was effectively treated with two overlapping Viabahn-covered stents, which completely excluded the pseudoaneurysm. Follow-up imaging at two months showed two well-positioned overlapping self-expanding stents with total occlusion of the pseudoaneurysm.

Successful Endovascular Treatment of Postbiopsy AVF in Transplanted Kidneys: Lessons Learned from Two Cases in Multiorgan Transplant Recipients.

Allograft biopsy is a cornerstone in the management of transplanted kidneys. It is a safe procedure, often performed in the outpatient setting. A rare complication is formation of a postbiopsy arteriovenous fistula (AVF). We present here a report of two cases of postbiopsy AVFs treated endovascularly. Selective embolization is a safe and effective method of treatment of postbiopsy AVFs in renal allografts.

Hybrid approach to deep vein arterialization as an adjunct for patients with severe medial calcinosis.

Patients with no-option chronic limb-threatening ischemia are not candidates for conventional revascularization options and will inevitably require major amputation. Deep venous arterialization (DVA) is a potential option for these patients. A complete endovascular system to perform DVA has recently received great acclaim and US Foor and Drug Administration approval. However, patients with severe tibial medial calcinosis such as those with diabetes or renal failure may not be candidates for this because most endovascular needles cannot penetrate severe calcium. Here we describe a novel hybrid approach to DVA that provided technical success in three patients with end-stage renal disease and severe medial calcinosis.

A Five-Year Retrospective Study from a Single Center on the Location, Presentation, Diagnosis, and Management of 110 Patients with Aneurysms of the Femoral and Popliteal Arteries of the Lower Limb.

Background: Peripheral aneurysms, although known about for centuries, are challenging to monitor due to their asymptomatic nature. Advanced imaging has improved detection, which is crucial for preventing emergent complications. This five-year retrospective study from a single center aimed to evaluate the location, presentation, diagnosis, and management of 110 patients with aneurysms of the femoral and popliteal arteries of the lower limb. Materials and methods: The study included 71 true aneurysms and 39 pseudoaneurysms patients treated between 2018-2023. Treatment methods were based on aneurysm size, atherosclerosis severity, and operation risk. The study assessed patient demographics, surgical details, postoperative complications, and aneurysm characteristics. Results: Acute limb ischemia was more prevalent in true aneurysms (25.4% vs. 7.7%; p = 0.02). Aneurysmectomy was performed more frequently in pseudoaneurysms (87.2% vs. 54.9%; p < 0.001), while endovascular treatment and surgical bypass were more common in true aneurysms (Endovascular: 22.5% vs. 2.6%; p = 0.01; bypass: 21.1% vs. 0%; p < 0.001). Early postoperative complications occurred in 22.7% of patients. The 12-month freedom from reoperations (73.7% vs. 87%; p = 0.07), amputations (97.7% vs. 93.8%; p = 0.2), and graft stenosis (78.7% vs. 86.87%; p = 0.06) showed no significant differences between groups. Conclusions: Lower limb aneurysms often present with non-specific symptoms, leading to late diagnosis and life-threatening complications. Both open and endovascular treatments are feasible, though more research is needed for pseudoaneurysms. Vigilant follow-up is crucial due to potential adverse events, though overall mortality and morbidity remain low.

Branch Thrombus after Endovascular Treatment with Arch Branched Devices for Aortic Arch Pathologies.

OBJECTIVE: The aim of this study was to describe the occurrence of branch thrombosis following endovascular treatment of aortic arch pathology using an arch branched device (ABD) and to determine whether this is influenced by clinical and geometric parameters. METHODS: In this retrospective observational study of patients treated with an ABD in three centres, the primary endpoint was thrombus formation within a branch during follow up. Secondary endpoints were technical success, serious adverse events (SAEs), early and late death, stroke, and re-interventions. Geometric measurements (tortuosity index and curvature) were determined on pre- and post-operative computed tomography angiograms. RESULTS: Thirty nine patients were treated and 68 antegrade branches were analysed (innominate artery, n = 27; common carotid artery [CCA], n = 40; left subclavian artery [LSA], n = 1). Thrombus was identified within seven branches (10%) on surveillance imaging (innominate artery, n = 6; CCA, n = 1; LSA, n = 0; p = .021) and was associated with a wider distal bridging stent diameter (median 14.0 mm [13.3, 15.3] vs. 8.7 mm [IQR 5.9]; p = .026), a higher degree of reversed tapering (4.3 mm [3.8, 5.2] vs. 1.2 mm [0.3, 3.1]; p = .023), use of polyethylene terephthalate (Dacron) covered (vs. expanded polytetrafluoroethylene) bridging stents (23% vs. 2%; p = .011), and higher body mass index (BMI) (32.1 kg/m2 [28.7, 36.2] vs. 25.7 kg/m2 [23.8, 29.2]; p = .029), but not with pre-operative or post-operative tortuosity index or curvature or alterations. Regarding secondary outcomes, the technical success rate was 97%, SAEs occurred in 15 patients (38%), early and late death rates were 8% and 23%, respectively, and early and late stroke rates were 5% and 23%, respectively. CONCLUSION: The risk of developing branch thrombosis after endovascular intervention with an ABD is considerable, especially of innominate artery branches, characterised by Dacron covered large diameter bridging stents, and in patients with a high BMI. Large prospective studies are required to analyse factors associated with branch thrombosis.

Optimal Catheter Selection for Patients with Acute Stroke with Type III Aortic Arch Based on Magnetic Resonance Angiography Road Mapping of the Para-Aortic Transfemoral Access Route Before Mechanical Thrombectomy.

BACKGROUND: Although mechanical thrombectomy for acute ischemic stroke has a high recanalization rate, procedurally challenging lesions remain in approximately 10% of the cases. Type III aortic arches, due to their anatomical configuration, are a fundamental problem impacting this procedure. This study aimed to determine whether optimal catheter selection for type III aortic arches, using magnetic resonance angiography (MRA)-based road mapping of the para-aortic transfemoral access route, reduces the time required for mechanical thrombectomy. METHODS: We retrospectively evaluated 203 consecutive patients who underwent mechanical thrombectomy at multiple centers between April 2018 and July 2022. 23 patients were diagnosed with a type III aortic arch using MRA-based road mapping performed to visualize the para-aortic access route before neuro-interventional procedures. Among the 23 patients with type III aortic arches, 10 received a Simmons-type catheter (initial Simmons group) and 13 received a JB-2-type catheter (initial JB-2 group) as their first inner catheter. The time required for mechanical thrombectomy was compared between the groups. RESULTS: Compared with the initial JB-2 group, the initial Simmons group exhibited a significantly shorter "puncture-to-recanalization time" (105 vs. 53 minutes, P = 0.009) and "door-to-recanalization time" (164 vs. 129 minutes, P = 0.032). CONCLUSIONS: Optimal catheter selection by identifying the aortic arch before mechanical thrombectomy using MRA-based road mapping effectively reduced the mechanical thrombectomy time. This suggests that even in type III aorta cases, appropriate catheter selection may shorten the mechanical thrombectomy time and improve acute ischemic stroke prognosis.

Facial nerve palsy after middle meningeal artery embolization for chronic subdural hematoma: a case report.

Middle meningeal artery embolization (MMAE) has emerged as a safe and efficacious alternative to surgery for the treatment of new or recurrent chronic subdural hematoma (CSDH). Several complications such as facial palsy may suddenly occur even in the absence of evident dangerous anastomoses in the angiogram. We herein present a case-report of left facial nerve palsy after MMAE.

Impact of Infrapopliteal Revascularisation Establishing In Line Flow to the Wound in Patients with Chronic Limb Threatening Ischaemia.

OBJECTIVE: This study aimed to determine the impact of infrapopliteal (IP) revascularisation establishing in line flow to the wound (IFW) on wound healing in chronic limb threatening ischaemia (CLTI), using a core laboratory assessment for wounds and in line flow. METHODS: The Wound directed Angiosome RevasculaRIsation apprOach to patients with cRitical limb iSchaemia (WARRIORS) multicentre observational study enrolled patients with CLTI with tissue loss undergoing IP revascularisation in Japan, with scheduled two year follow up. The primary outcome measure was complete wound healing, defined as achievement of complete epithelialisation of all wounds without major amputation. IP revascularisation establishing IFW was defined as revascularisation after which a tibiopedal artery that actually fed an injured pedal unit was patent. The incidence of wound healing was compared between the IFW and non-IFW groups using inverse probability of treatment weighting based on the propensity score. RESULTS: A total of 440 patients with CLTI (median age, 75 years; male, 64.1%; diabetes mellitus, 72.0%; dialysis, 57.7%) with tissue loss (Wound, Ischaemia, and foot Infection stage 4, 66.4%) who underwent IP revascularisation (endovascular procedure, n = 304; bypass grafting, n = 136) between October 2017 and June 2020 were registered. During a median follow up of 23.6 months, 51.1% achieved wound healing. Successful IP revascularisation with IFW was achieved in 68.2%. After analysis, the IFW group had a higher rate of wound healing than the non-IFW group (34.5 vs. 16.1 per 100 person years; p = .030). The association between IFW and wound healing was not statistically different between patients undergoing bypass grafting and those undergoing an endovascular procedure (p for interaction = .38). There was no statistically significant interaction effect between IFW and direct revascularisation for wound healing (p for interaction = .51). CONCLUSION: IP revascularisation establishing IFW was statistically significantly associated with a higher wound healing rate in patients with CLTI.

Comparison of open and endovascular left subclavian artery revascularization for zone 2 thoracic endovascular aortic repair.

OBJECTIVE: In patients undergoing elective thoracic endovascular aortic repair (TEVAR) and left subclavian artery (LSA) coverage, routine preoperative LSA revascularization is recommended. However, in the current endovascular era, the optimal surgical approach is debated. We compared baseline characteristics, procedural details, and perioperative outcomes of patients undergoing open or endovascular LSA revascularization in the setting of TEVAR. METHODS: Adult patients undergoing TEVAR with zone 2 proximal landing and LSA revascularization between 2013 and 2023 were identified in the Vascular Quality Initiative. We excluded patients with traumatic aortic injury, aortic thrombus, or ruptured presentations, and stratified based on revascularization type (open vs any endovascular). Open LSA revascularization included surgical bypass or transposition. Endovascular LSA revascularization included single-branch, fenestration, or parallel stent grafting. Primary outcomes were stroke, spinal cord ischemia (SCI), and perioperative mortality (Pearson's χ2 test). Multivariable logistic regression was used to evaluate associations between revascularization type and primary outcomes. Secondarily, we studied other in-hospital complications and 5-year mortality (Kaplan-Meier, multivariable Cox regression). Sensitivity analyses were performed in patients undergoing concomitant LSA revascularization to TEVAR. RESULTS: Of 2489 patients, 1842 (74%) underwent open and 647 (26%) endovascular LSA revascularization. Demographics and comorbidities were similar between open and endovascular cohorts. Compared with open, endovascular revascularization had shorter procedure times (median, 135 minutes vs 174 minutes; P < .001), longer fluoroscopy times (median, 23 minutes vs 16 minutes; P < .001), lower estimated blood loss (median, 100 mL vs 123 mL; P < .001), and less preoperative spinal drain use (40% vs 49%; P < .001). Patients undergoing endovascular revascularization were more likely to present urgently (24% vs 19%) or emergently (7.4% vs 3.4%) (P < .001). Compared with open, endovascular patients experienced lower stroke rates (2.6% vs 4.8%; P = .026; adjusted odds ratio [aOR], 0.50 [95% confidence interval (CI), 0.25-0.90]), but had comparable SCI (2.9% vs 3.5%; P = .60; aOR, 0.64 [95% CI, 0.31-1.22]) and perioperative mortality (3.1% vs 3.3%; P = .94; aOR, 0.71 [95% CI, 0.34-1.37]). Compared with open, endovascular LSA revascularization had lower rates of overall composite in-hospital complications (20% vs 27%; P < .001; aOR, 0.64 [95% CI, 0.49-0.83]) and shorter overall hospital stay (7 vs 8 days; P < .001). After adjustment, 5-year mortality was similar among groups (adjusted hazard ratio, 0.85; 95% CI, 0.64-1.13). Sensitivity analyses supported the primary analysis with similar outcomes. CONCLUSIONS: In patients undergoing TEVAR starting in zone 2, endovascular LSA revascularization had lower rates of postoperative stroke and overall composite in-hospital complications, but similar SCI, perioperative mortality, and 5-year mortality rates compared with open LSA revascularization. Future comparative studies are needed to evaluate the mid- to long-term safety of endovascular LSA revascularization and assess differences between specific endovascular techniques.

Infrapopliteal Peripheral Vascular Interventions for Claudication are Performed Frequently in the USA and Are Associated with Poor Long Term Outcomes.

OBJECTIVE: Infrapopliteal peripheral vascular interventions (PVIs) for claudication are still performed in the USA. This study aimed to evaluate whether infrapopliteal PVI is associated with worse long term outcomes than isolated femoropopliteal PVI for treatment of claudication. METHODS: A retrospective analysis of fee for service claims in a national administrative database was conducted using 100% of the Medicare fee for service claims between 2017 and 2019 to capture all Medicare beneficiaries who underwent an index infra-inguinal PVI for claudication. Hierarchical Cox proportional hazards models were performed to assess the association of infrapopliteal PVI with conversion to chronic limb threatening ischaemia (CLTI), repeat PVI, and major amputation. RESULTS: In total, 36 147 patients (41.1% female; 89.7% age ≥ 65 years; 79.0% non-Hispanic White ethnicity) underwent an index PVI for claudication, of whom 32.6% (n = 11 790) received an infrapopliteal PVI. Of these, 61.4% (n = 7 245) received a concomitant femoropopliteal PVI and 38.6% (n = 4 545) received an isolated infrapopliteal PVI. The median follow up time was 3.5 years (interquartile range 2.7, 4.3). Patients receiving infrapopliteal PVI had a higher three year cumulative incidence of conversion to CLTI (26.0%; 95% confidence interval [CI] 24.9 - 27.2% vs. 19.9%; 95% CI 19.1 - 20.7%), repeat PVI (56.0%; 95% CI 54.8 - 57.3% vs. 45.7%; 95% CI 44.9 - 46.6%), and major amputation (2.2%; 95% CI 1.8 - 2.6% vs. 1.3%; 95% CI 1.1 - 1.5%) compared with patients receiving isolated femoropopliteal PVI. After adjusting for patient and physician level characteristics, the risk of conversion to CLTI (adjusted hazard ratio [aHR] 1.31, 95% CI 1.23 - 1.39), repeat PVI (aHR 1.12, 95% CI 1.05 - 1.20), and major amputation (aHR 1.72, 95% CI 1.42 - 2.07) remained significantly higher for patients receiving infrapopliteal PVI. An increasing number of infrapopliteal vessels treated during the index intervention was associated with increasingly poor outcomes (p < .001 for trend). CONCLUSION: Infrapopliteal PVI for claudication is associated with worse long term outcomes relative to isolated femoropopliteal PVI.

Editor's Choice - Covered Stents Versus Bare Metal Stents in the Treatment of Aorto-iliac Disease: A Systematic Review and Individual Participant Data Meta-analysis.

OBJECTIVE: To assess the comparative safety and efficacy of covered stents (CS) and bare metal stents (BMS) in the endovascular treatment of aorto-iliac disease in patients with peripheral arterial disease. DATA SOURCES: A systematic review was conducted adhering to the PRISMA 2020 and PRISMA for Individual Participant Data 2015 guidelines. REVIEW METHODS: A search of PubMed, Scopus, and Web of Science for articles published by December 2023 was performed. The primary endpoint was primary patency. Certainty of evidence was assessed via the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. RESULTS: Eleven studies, comprising 1 896 patients and 2 092 lesions, were included. Of these, nine studies reported on patients' clinical status, with 35.5% classified as Rutherford 4 - 6. Overall primary patency for CS and BMS at 48 months was 91.2% (95% confidence interval [CI] 84.1 - 99.0%) (GRADE, moderate) and 83.5% (95% CI 70.9 - 98.3%) (GRADE, low). The one stage individual participant data meta-analyses indicated a significant risk reduction for primary patency loss favouring CS (hazard ratio [HR] 0.58, 95% CI 0.35 - 0.95) (GRADE, very low). The 48 month primary patency for CS and BMS when treating TransAtlantic Inter-Society Consensus (TASC) C and D lesions was 92.4% (95% CI 84.7 - 100%) (GRADE, moderate) and 80.8% (95% CI 64.5 - 100%) (GRADE, low), with CS displaying a decreased risk of patency loss (HR 0.39, 95% CI 0.27 - 0.57) (GRADE, moderate). While statistically non-significant differences were identified between CS and BMS regarding technical success, 30 day mortality rate, intra-operative and immediate post-operative procedure related complications, and major amputation, CS displayed a decreased re-intervention risk (risk ratio 0.59, 95% CI 0.40 - 0.87) (GRADE, low). CONCLUSION: This review has illustrated the improved patency of CS compared with BMS in the treatment of TASC C and D lesions. Caution is advised in interpreting overall primary patency outcomes given the substantial inclusion of TASC C and D lesions in the analysis. Ultimately, both stent types have demonstrated comparable safety profiles.

Editor's Choice - Development of a Risk Prediction Nomogram for Carotid Re-Stenosis in the One Year RECAST Registry.

OBJECTIVE: The long term benefit of carotid angioplasty and stenting (CAS) can be reduced by recurrent stroke related to in stent re-stenosis (ISR). An individualised predictive tool is needed to identify ISR events. A nomogram for individual risk assessment of ISR ≥ 70% after CAS is proposed. METHODS: A national observational, prospective, multicentre registry was conducted between January 2015 and December 2020. Cohorts of patients with symptomatic or asymptomatic severe carotid stenosis who underwent CAS with a follow up of at least one year after CAS were included. Duplex ultrasound was used to assess in stent re-stenosis. Pre-operative factors were compared between the non-ISR and ISR groups. Kaplan-Meier and Cox regression were used for variable selection. The nomogram was formulated and validated by concordance indices and calibration curves. An in stent re-stenosis risk table was generated for risk stratification. RESULTS: A total of 354 patients were included in the analysis. The ISR rate of ≥ 70% was 7.6% (n = 27). Peripheral arterial disease (hazard ratio [HR] 3.18, 95% confidence interval [CI] 1.23 - 8.24, p = .017), anterior communicating artery absence (HR 3.38, 95% CI 1.27 - 8.94, p = .016), diabetes mellitus (HR 3.34, 95% CI 1.21 - 9.26, p = .020), female sex (HR 2.99, 95% CI 1.04 - 8.60, p = .041), and pre-procedure pathological ultrasound vasoreactivity (HR 3.87, 95% CI 1.43 -10.50, p = .008), as independent risk factors for ISR of ≥ 70%, were included in the nomogram. The concordance index at 12 and 24 months was 0.83. In low risk groups, ISR of ≥ 70% occurred in 4.8% of patients during follow up compared with 56.2% of patients in the high risk groups (p < .001). CONCLUSION: The nomogram and risk evaluation score have good predictive ability for ISR. They can be used as practical clinical tools for individualised risk assessment.

Efficacy and Safety of a New Delivery Assist Catheter with a Flexible, Spindle-Shaped Shaft in Mechanical Thrombectomy.

OBJECTIVE: Large-bore aspiration catheters (ACs) are used successfully in mechanical thrombectomy (MT). However, tortuous access routes prevent device navigation because of the ledge effect. The AXS Offset Delivery Assist Catheter is designed to reduce the ledge effect. The purpose of this study was to evaluate whether the Offset affects AC navigation compared with standard inner microcatheters in MT. METHODS: We retrospectively investigated 75 MTs for anterior circulation occlusion between January 2018 and May 2022 at our hospital. All MTs were performed using an AC, and 2 types of inner microcatheter (Offset or 0.021-0.027-inch standard microcatheter) were chosen randomly during AC navigation. The patients' characteristics, MT techniques, angiographic findings, and clinical outcomes were compared between the Offset and standard group (Non-Offset). The puncture to first pass of the lesion time was investigated to compare the characteristics of the inner catheters. RESULTS: The Offset group comprised 12 patients versus 63 in the Non-Offset group. Although most baseline clinical characteristics and outcomes were similar between the groups, the puncture to first pass of the lesion time was significantly shorter in the Offset versus Non-Offset group (31 ± 10 vs. 46 ± 24 minutes, respectively; P = 0.032). In the Offset group, all stent retrievers were deployed via the Offset. One artery dissection and 8 symptomatic intracranial hemorrhages occurred in the Non-Offset group; no complications occurred in the Offset group. CONCLUSIONS: The AXS Offset delivery assist catheter permitted faster and safer navigation of various ACs to the occlusions compared with standard delivery microcatheters in MT.

Factors predicting recanalization following stent-assisted coil embolization of unruptured intracranial aneurysms with long-term follow-up.

Objective: Stents have been widely used for coil embolization for intracranial aneurysms. Few studies have analyzed the risk factors of recanalization through long-term follow-up observation of only stent-assisted coiling. We analyzed the risk factors for recanalization through long-term observations. Methods: A total number of 399 unruptured aneurysms treated by stent-assisted coil embolization between 2003 and 2016 in a single institution were analyzed for determining the factors associated with recanalization including the patient characteristics, aneurysms, and procedural variables. All patients underwent angiographic follow-up with digital subtraction angiography or magnetic resonance angiography at 24 months or more following the procedure. Results: Recanalization occurred in 8%. The mean time for the recanalization was 21.1 ± 14.0 months (range, 5-51 months). The receiver operating characteristic curve analysis indicated areas under the curve for a maximum aneurysm size of 0.773 (cut-off, 6.415 mm). Multivariate analysis revealed that the maximum aneurysm size and parent artery curvature at which the aneurysm developed were significantly associated with recanalization. In parent artery curvature, the bifurcation group (OR, 9.02; 95% CI, 2.53-32.13; p = 0.001) and the convex group (OR, 3.68; 95% CI, 1.17-11.50; p = 0.025) were independent predictors of recanalization compared with the straight group. Conclusion: The maximum aneurysm size and parent artery curvature are risk factors associated with recanalization in stent-assisted coil embolization.