Feasibility of early radial artery occlusion recanalization and reuse through transradial access for neuroendovascular procedures.

BACKGROUND: Radial artery occlusion (RAO) remains a significant limitation of neuroendovascular procedures peformed through transradial access (TRA) when radial artery needs to be reused. Instances of early RAO recanalization to successfully complete neuroendovascular procedures have been rarely documented. MATERIALS AND METHODS: Documents and imaging data were extracted retrospectively for all patients who underwent TRA diagnostic angiography and neuroendovascular procedures in our center from June 2022 to February 2023. The patients with early RAO who required repeat TRA were included. RESULTS: A total of 46 patients underwent repeat TRA, and 13 consecutive patients who experienced early RAO after angiography as confirmed by ultrasonography were enrolled in this study. The occluded radial arteries were successfully recanalized, and subsequent neuroendovascular procedures were carried out successful. During an average follow-up time of 7.1 months, no patients exhibited symptomatic RAO, dissection, hematoma or pseudoaneurysm. CONCLUSIONS: Early RAO recanalization and reused for neuroendovascular procedures through TRA is feasible. A visually guided and stable puncture process plays a crucial role in successfully recanalizing early RAO.

Comparison of acetylsalicylic acid and clopidogrel non-responsiveness assessed by light transmittance aggregometry and PFA-100® in patients undergoing neuroendovascular procedures.

Objectives: Dual platelet inhibition is commonly used for prevention of cardiovascular events in patients undergoing neuroendovascular procedures. Non-responsiveness to platelet inhibitors may be associated with adverse outcomes. The aim of this study was to evaluate the reliability of the platelet function analyzer PFA-100® in comparison to light transmittance aggregometry (LTA) for monitoring clopidogrel and acetylsalicylic acid (ASA) non-responsiveness in a cohort of patients treated for intracranial aneurysm or cranial artery stenosis. Methods: Non-responsiveness to clopidogrel and ASA was assessed by LTA using adenosine diphosphate (ADP) and arachidonic acid and by PFA-100® with the ADP/prostaglandin E1 (PGE1) and collagen/epinephrine cartridges, respectively. Results: A total of 203 patients (145 females; median age, 57 years) were analyzed. Agreement between the two tests was poor for clopidogrel non-responsiveness (ƙ=0.19) and not better than chance for ASA non-responsiveness (ƙ=0.01). Clopidogrel non-responsiveness by LTA and PFA-100® was associated with higher von Willebrand factor antigen and activity levels. ADP-induced platelet disaggregation was lower in patients with clopidogrel non-responsiveness as assessed by PFA-100®. Clopidogrel non-responsiveness by LTA was associated with a higher prevalence of diabetes and a higher body mass index (BMI). Adverse outcomes (death, thromboembolism, or in-stent thrombosis) occurred in 13% (n=26) of all patients independently of ASA and clopidogrel non-responsiveness as assessed by both devices. Conclusions: Our results show that LTA and PFA-100® are not interchangeable in the assessment of ASA and clopidogrel non-responsiveness in patients undergoing neuroendovascular interventions.

Assessment of Blood Loss during Neuroendovascular Procedures.

(1) Background: Neuroendovascular procedures have generally been considered to have minor or inconsequential blood loss. No study, however, has investigated this question. The purpose of this study is to quantify the blood loss associated with neuroendovascular procedures and identify predictors of blood loss, using hemoglobin change as a surrogate for blood loss. (2) Methods: A retrospective review of 200 consecutive endovascular procedures (diagnostic and therapeutic) at our institution from January 2020 to October 2020 was performed. Patients had to have pre- and post-operative hematocrit and hemoglobin levels recorded within 48 h of the procedure (with no intervening surgeries) for inclusion. (3) Results: The mean age of our cohort was 60.1 years and the male representation was 52.5%. The mean pre-operative hemoglobin/hematocrit was significantly lower among females compared to males (12.1/36.2 vs. 13.0/38.5, p = 0.003, p = 0.009). The mean hemoglobin decrease was 0.5 g/dL for diagnostic angiograms compared to 1.2 g/dL for endovascular interventions (p < 0.0001), and 1.0 g/dL for all procedures combined. In a multivariate linear regression analysis, pre-operative antiplatelet/anticoagulant use was associated with a statistically significant decrease in hemoglobin. (4) Conclusions: Our data support that blood loss from diagnostic angiograms is marginal. Blood loss in endovascular interventions, however, tends to be higher. Pre-operative blood antiplatelet/anticoagulant use and increasing age appear to increase bleeding risk and may require closer patient monitoring.

Increased Multispectral CT Iodine Concentrations in Patients With Transient Neurological Deterioration Following Endovascular Neurointerventional Procedures: an Argument in Favor of the Elusive Contrast-Induced Encephalopathy?

BACKGROUND AND PURPOSE: So-called contrast-induced encephalopathy (CIE) is a rare but worrying condition occurring after cerebral angiography or neuroendovascular interventions using iodine contrast media. This study aimed to compare cerebral iodine concentrations in patients suspected of having CIE after endovascular procedures to those in matched controls. METHODS: This is a retrospective monocentric study of 25 suspected CIE patients in a tertiary care teaching hospital diagnosed from June 2017 to February 2024. Cerebral multispectral computed tomography (CT) iodine mean concentrations were measured and compared with 1:1 matched controls using the CT constructor's workstation in the whole brain and in specific regions of interest (ROIs) corresponding to a vascular territory downstream of the procedure. Concentration values were compared with paired samples t­test. RESULTS: During the study period, 1097 patients underwent aneurysm embolization and 137 arteriovenous malformation (AVM) embolization procedures. So-called CIE was suspected in 25 patients after aneurysm or AVM embolization (2%). Mean iodine concentrations in the procedure vascular territory ROIs were higher in suspected CIE cases (mean 543 ± 147 µg/cm3) compared to matched controls (mean 463 ± 141 µg/cm3; p = 0.01). Whole brain mean iodine concentrations were modestly higher in CIE patients compared to controls across all subgroups, without reaching statistical significance. CONCLUSIONS: CIE may be associated with modest increase in CT iodine concentration in the procedure vascular territory after neurointerventional procedures. The underlying pathophysiology of this condition remains uncertain and merits further investigation. KEY MESSAGES: Contrast-induced encephalopathy (CIE) is known as a rare neurologic condition following iodine contrast media use in neuroendovascular interventions, with unclear pathophysiology. WHAT THIS STUDY ADDS: This study provides evidence that suspected CIE is associated with higher cerebral iodine concentrations in affected vascular territories, a novel quantifiable change. Implications for research, practice, or policy: These findings suggest the potential for iodine concentration monitoring to refine CIE diagnosis and prevention strategies in clinical practice.

Endovascular Embolization of Femoral Pseudoaneurysm Associated with Therapeutic and Diagnostic Neuroendovascular Procedures.

Objective: We aimed to evaluate the usefulness of endovascular embolization for femoral iatrogenic pseudoaneurysms (PAs) following therapeutic and diagnostic neuroendovascular procedures. Methods: This study included 12 patients with femoral PA due to femoral puncture at our department between May 2014 and April 2021. We performed an analysis of baseline characteristics, treatment, and outcome of these cases. Results: Endovascular embolization was performed in 10 of the 12 PAs using coils and/or N-butyl-2-cyanoacrylate. Of these, 10 PAs were treated with endovascular embolization and 9 were successfully occluded, whereas complete occlusion was not achieved in 1 case of PA (success rate: 90%). No new intraoperative or postoperative complications or postoperative recurrences occurred. Conclusion: Endovascular embolization for PA can be immediately performed under local anesthesia without discontinuation of antithrombotic therapy and may be a safe and effective option for access site complication treatment.

Neuroendovascular Procedures in Patients with Ehlers-Danlos Type IV: Multicenter Case Series and Systematic Review.

BACKGROUND: Ehlers-Danlos type IV or vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited disorder characterized by profound vascular fragility resulting from defective production of type III procollagen. Cerebrovascular diseases including spontaneous dissections, cerebral aneurysms, and cavernous carotid fistulae are common. Endovascular therapies in this patient population are known to be higher risk, although many studies (before 2000) involved older techniques and equipment. The purpose of this study is to investigate the safety and efficacy of modern neuroendovascular techniques in the treatment of cerebrovascular diseases in patients with vEDS. METHODS: We combined a multi-institutional retrospective case series at 3 quaternary-care centers with a systematic literature review of individual case reports and case series spanning 2000-2021 to evaluate the safety and efficacy of neuroendovascular procedure in patients with vEDS with cerebrovascular diseases. RESULTS: Fifty-nine patients who underwent 66 neuroendovascular procedures were evaluated. Most of the patients had direct cavernous carotid fistulas (DCCF). Neuroendovascular procedures had a 94% success rate, with a complication rate of 30% and a mortality of 7.5%. CONCLUSIONS: Neuroendovascular procedures can be performed with a high rate of success in the treatment of cerebrovascular diseases in patients with vEDS, although special care is required because complication rates and mortality are high. Access site and procedure-related vascular injuries remain a significant hurdle in treating vEDS with cerebrovascular diseases, even with modern techniques.

Changes in Neuroendovascular Procedural Volume During the COVID-19 Pandemic: An International Multicenter Study.

BACKGROUND AND PURPOSE: The effect of coronavirus disease 2019 (COVID-19) pandemic on performance of neuroendovascular procedures has not been quantified. METHODS: We performed an audit of performance of neuroendovascular procedures at 18 institutions (seven countries) for two periods; January-April 2019 and 2020, to identify changes in various core procedures. We divided the region where the hospital was located based on the median value of total number of COVID-19 cases per 100,00 population-into high and low prevalent regions. RESULTS: Between 2019 and 2020, there was a reduction in number of cerebral angiograms (30.9% reduction), mechanical thrombectomy (8% reduction), carotid artery stent placement for symptomatic (22.7% reduction) and asymptomatic (43.4% reduction) stenoses, intracranial angioplasty and/or stent placement (45% reduction), and endovascular treatment of unruptured intracranial aneurysms (44.6% reduction) and ruptured (22.9% reduction) and unruptured brain arteriovenous malformations (66.4% reduction). There was an increase in the treatment of ruptured intracranial aneurysms (10% increase) and other neuroendovascular procedures (34.9% increase). There was no relationship between procedural volume change and intuitional location in high or low COVID-19 prevalent regions. The procedural volume reduction was mainly observed in March-April 2020. CONCLUSIONS: We provided an international multicenter view of changes in neuroendovascular practices to better understand the gaps in provision of care and identify individual procedures, which are susceptible to change.

Intraprocedural Back Pain Associated with Awake Neuroendovascular Procedures.

BACKGROUND AND PURPOSE: The prevalence and characteristics of intraprocedural back pain is not well studied in awake patients undergoing neuroendovascular procedures. METHODS: We performed a prospective study as part of quality improvement initiative in which all patients who underwent neuroendovascular procedures in awake state were inquired regarding presence, severity (using a numeric rating scale score ranging from 0 [no pain] to 10 [worst pain possible]), and location (using anatomical chart) of back pain immediately after the procedure. The primary endpoint was the proportion of patients with moderate to severe pain (score of ≥3). RESULTS: A total of 100 (41.3%) of 242 patients reported intraprocedural back pain with a median severity of 5/10 (range 1-10). The mean age was 58.7 ± 16.2 years. The mean duration of the procedure was 82.3 minutes (range 15-410 minutes). The pain was classified as moderate to severe in 86 of 100 patients. The locations of pain were identified in lumbar (n = 77), thoracic (n = 6), cervical (n = 7), cervical and lumbar (n = 8), and cervical with thoracolumbar (n = 2) regions. There was a significant relationship between patients' history of the previous neck and/or back surgery and frequency of moderate to severe back pain (P = .02). No significant relationship was observed between frequency of none to mild and moderate to severe back pain among the strata by patients' age, body mass index, or duration of procedures. CONCLUSIONS: The relatively high prevalence of intraprocedural back pain in patients undergoing neuroendovascular procedures in awake state must be recognized, and strategies to reduce the occurrence need to be identified.

Femoral Neuropathy Following Transfemoral Neuroendovascular Procedures. An Analysis of a Prospective Registry.

BACKGROUND AND PURPOSE: Although femoral neuropathy is recognized as an adverse consequence following transfemoral neuroendovascular procedures, no reliable estimates are available. We analyzed data from a prospective registry to ascertain the frequency and characteristics of femoral neuropathy following transfemoral neuroendovascular procedures. METHODS: Consecutive patients who underwent neuroendovascular procedures through the transfemoral route were included. Detailed assessment was performed if any patient reported occurrence of sensory or motor symptoms in the femoral or lower extremity region including neurological examination (sensory/motor deficits) and femoral region ultrasound. RESULTS: Femoral neuropathy was diagnosed following 4 of 270 neurovascular procedures with an occurrence rate of 1.5% (95% confidence intervals = .4-3.7%). The symptoms were exclusively sensory without any motor involvement. The femoral neuropathy appeared to involve anterior femoral cutaneous nerves in all and medial cutaneous branches in 2 patients, and more than one nerve distribution in 1 patient in whom lateral cutaneous nerve appeared to be involved. All patients reported resolution of symptoms within a period ranging from 1 week to 2 months. No local hematoma or arterial pseudoaneurysm was identified at femoral region ultrasound. CONCLUSIONS: Femoral neuropathy is a rare occurrence following transfemoral neuroendovascular procedures and it usually occurs with pure sensory manifestations with complete resolution.

Modern Training and Credentialing in Neuroendovascular Acute Ischemic Stroke Therapy.

BACKGROUND: Acute ischemic stroke (AIS) remains a significant source of morbidity and mortality worldwide. Multiple recent randomized clinical trials for AIS patients presenting with large vessel occlusion have demonstrated radical improvement in outcomes with mechanical thrombectomy (MT), which is now recognized as the new standard of care for patients presenting up to 24 hr. OBJECTIVE: To provide a perspective on training and credentialing requirements for practitioners in this field. METHODS: Relevant articles were systematically searched and analyzed. Standards for Reporting Qualitative Research guidelines were utilized. RESULTS: : The Committee for Advanced Subspecialty Training (CAST) brings together the principal specialties of Radiology, Neurology, and Neurosurgery. Their training standards document the most recent consensus on training for neuroendovascular surgery (NES) and include the endovascular treatment of AIS as a part of the field of NES. This unified consensus represents a significant landmark in the evolution of stroke therapy. Presently, training at most centers follows an apprenticeship type model. Simulation methods and objective performance metrics have not been widely incorporated. Maintenance of proficiency has not been conclusively addressed reflecting the overall developing nature of the field. CONCLUSION: The evolution of the standard of care interventional therapy for large vessel AIS utilizing MT raises concerns regarding work force needs, training standards, competency, and credentialing requirements for practitioners. The CAST framework represents the most modern and flexible approach for both individuals and training programs. Methods based on objective performance metrics utilizing simulation as primary vehicle may be the logical next steps in the evolution of NES.