Predictors of occlusion, long-term outcomes, and safety in a cohort of 674 aneurysms treated with the Pipeline embolization device.

OBJECTIVE: By providing a more physiological approach to the treatment of intracranial aneurysms, the Pipeline embolization device (PED) has revolutionized the endovascular treatment of aneurysms. Although there are many flow diverters on the market, the authors report their experience with the PED, the first flow diverter to be approved by the Food and Drug Administration. They aimed to assess the efficacy and safety of PED flow diversion for the treatment of a wide range of aneurysms, as well as to look at factors affecting occlusion. METHODS: This is a retrospective study of a prospectively maintained database of patients treated with the PED between January 2011 and December 2019. Charts were reviewed for patient, aneurysm, and procedure characteristics. The primary outcomes of interest were complication rates, occlusion outcomes (O'Kelly-Marotta grading scale), and functional outcomes (modified Rankin Scale [mRS]). Secondary outcomes included predictors of incomplete occlusion at 6 and 24 months of follow-up. RESULTS: The study cohort included 581 patients with 674 aneurysms. Most aneurysms (90.5%) were in the anterior circulation and had a saccular morphology (85.6%). Additionally, 638 aneurysms (94.7%) were unruptured, whereas 36 (5.3%) were acutely ruptured. The largest mean aneurysm diameter was 8.3 ± 6.1 mm. Complications occurred at a rate of 5.5% (n = 32). The complete occlusion rate was 89.3% at 24 months' follow-up, and 94.8% of patients had a favorable neurological outcome (mRS score 0-2) at the last follow-up. On multivariate analysis, predictors of incomplete aneurysm occlusion at 6 months were hypertension (OR 1.7, p = 0.03), previous aneurysm treatment (OR 2.4, p = 0.001), and increasing aneurysm neck diameter (OR 1.2, p = 0.02), whereas a saccular morphology was protective (OR 0.5, p = 0.05). Predictors of incomplete occlusion at 24 months were increasing aneurysm neck diameter (OR 1.2, p = 0.01) and previous aneurysm treatment (OR 2.3, p = 0.01). CONCLUSIONS: The study findings are corroborated by those of previous studies and trials. The complete occlusion rate was 89.3% at 24 months' follow-up, with 94.8% of patients having favorable functional outcomes (mRS score 0-2). Aneurysm treatment before PED deployment and an increasing aneurysm neck diameter increase the risk of incomplete occlusion at 6 and 24 months.

Middle Meningeal Artery Embolization for Membranous Versus Nonmembranous Subdural Hematomas: A Retrospective and Multicenter Cohort Study.

BACKGROUND: Middle meningeal artery (MMA) embolization is a treatment option for chronic subdural hematomas (SDHs). The theorized mechanism of MMA embolization is devascularization of membranes that contribute to recurrence. In the present study, we aimed to determine whether MMA embolization is more efficacious for SDHs with radiographically visible membranes. METHODS: A multicenter, retrospective cohort study was performed of patients with SDHs who underwent MMA embolization alone or with burr hole drainage. The SDHs were categorized as membranous or nonmembranous according to the radiographic appearance. The patient characteristics and outcomes were compared between the 2 groups. RESULTS: A total of 99 patients with 117 MMA embolization procedures were included. Of the 99 patients, 73.7% with a membranous SDH and 61.0% with a nonmembranous SDH underwent MMA embolization alone. The remaining patients underwent MMA embolization in conjunction with burr hole evacuation. The overall recurrence rate was 10.7%. No significant differences were found in complications (P = 0.417), recurrence (P = 0.898), or retreatment (P = 0.999) among the membranous and nonmembranous groups. CONCLUSIONS: To the best of our knowledge, this is the first multicenter study evaluating the effect of membrane presence in SDHs undergoing embolization. Membrane presence in patients undergoing MMA embolization did not correlate with recurrence or retreatment, suggesting that membrane presence should not be used as the sole selection criterion for MMA embolization. Although prospective studies of larger cohorts are needed, the results from the present study provide information on the potential implications of membranes in determining the optimal treatment paradigm for SDHs.

Access Site Complications and Management of the Transradial Approach for Neurointerventions.

BACKGROUND: The transradial approach has increasingly been used for neurointerventions because of the improved safety profile compared with transfemoral. However, it is important to be aware of potential complications such as radial artery (RA) spasm, RA occlusion, pseudoaneurysm, extravasation, arteriovenous fistula, and wrist hematoma as well as their management. OBJECTIVE: To present our institution's experience with the prevention and management of local access site complications associated with the transradial approach for neuroendovascular interventions. METHODS: We conducted a retrospective analysis of a prospectively maintained database and identified 1524 consecutive neuroendovascular procedures performed using transradial access from April 2018 to February 2021. RESULTS: Among 1524 procedures, local transradial complications occurred in 1.7%. Major complications occurred at a rate of 1.2% including RA extravasation (0.3%), delayed RA occlusion (0.6%), pseudoaneurysm (0.1%), compartment syndrome (0.1%), infection (0.1%), and avulsion of the RA in 0.1% (1 of 1524) with no serious clinical consequence. Although RA occlusion is included in major complications, all cases were asymptomatic and did not require any intervention. Minor complications occurred at a rate of 0.5% including severe RA spasm (0.3%) and hematoma (0.3%). No patient in the cohort died or suffered from permanent disability from a complication related to the transradial approach. CONCLUSION: Transradial access for neurointervention has a low rate of local complications, particularly when taking appropriate prevention measures. Appropriate management of complications can prevent procedural failure and has low morbidity rates demonstrating the overall safety profile of transradial access even when complications occur.

Rescue stenting for acute ischemic stroke with refractory emergent large vessel occlusion in the modern thrombectomy era.

BACKGROUND AND PURPOSE: Rescue stenting is used as a bailout technique during mechanical thrombectomy for stroke. We performed a retrospective study analyzing outcomes of patients that received a stent as a bailout measure and compared results to a control group. METHODS: We identified all patients who underwent a mechanical thrombectomy for a large vessel occlusion between January 2010 and October 2019. Subjects with mTICI 0-2 A after at least three passes were defined as failed MT and constituted the control group (NSG-controls). Patients that received a rescue stent (RSG) formed the study group. RESULTS: Comparative analysis of patient demographics between NSG-controls and SRG was performed. Baseline characteristics and comorbidities were not significantly different between both groups. NIHSS at admission and IV t-PA were not significantly different among both groups (16.5 vs. 14.2, p = 0.19) and (39.4% vs. 29.4%, p = 0.30), respectively. There was no significant difference in procedural and post-procedural complications between both the groups. In the RSG, 24 patients (82.4%) achieved favorable revascularization outcomes. NIHSS at discharge (p = 0.01) was higher in the NSG-controls, while favorable functional outcome at three months (12% vs. 39.2%, p = 0.01) was observed at a higher proportion in the RSG. There was also a significant mortality difference, with 15.2% mortality in the RSG compared to 35.1% mortality in the NSG-controls (p = 0.03). In multivariate analysis, stenting was an independent predictor of favorable outcome (OR: 10.0, p = 0.009). CONCLUSION: Herein, we demonstrated that rescue stenting is a feasible, safe, and effective procedure to improve stroke outcomes and should be seriously considered if the primary mechanical thrombectomy is not successful.

Mechanical Thrombectomy in Patients Presenting with NIHSS Score <6: A Safety and Efficacy Analysis.

BACKGROUND AND OBJECTIVES: Groundbreaking trials have shown the tremendous efficacy of mechanical thrombectomy for large vessel occlusions. Currently, mechanical thrombectomy is limited to patients with NIHSS scores ≥6. We investigated the feasibility and safety of MT in patients presenting with NIHSS scores <6. MATERIALS AND METHODS: A retrospective review of patient who presented with acute ischemic stroke due to large vessel occlusion with an NIHSS score <6 between 2015 - 2021. The patients were then divided into two groups: those who received mechanical thrombectomy and those who did not. RESULTS: Among 83 patients, 41 received a mechanical thrombectomy while 42 received medical treatment only. The mean age in the mechanical thrombectomy group was 66 years versus 60 years in the medical group (p = 0.06). Risk factors for stroke did not differ significantly between both groups. 14 patients (34.1%) in the mechanical thrombectomy group and 20 (47.6%) in the medical group received tissue plasminogen activator. No significant difference in clinical improvement (NIHSS) at discharge (p=0.85) or the mRS score at 90 days (p = 0.15) was noted. Mechanical thrombectomy was associated with smaller infarct size (p=0.04) and decreased mortality (p=0.03). CONCLUSIONS: Mechanical thrombectomy is safe and effective for patients who present with large vessel occlusions and low initial NIHSS scores. Therefore, the decision to offer the patient mechanical thrombectomy or not should not be decided by NIHSS score alone. Rather, the decision should be multifactorial with the aim of maximizing the patients' outcomes.

Robot-assisted carotid artery stenting: outcomes, safety, and operational learning curve.

OBJECTIVE: Over the past 2 decades, robots have been increasingly used in surgeries to help overcome human limitations and perform precise and accurate tasks. Endovascular robots were pioneered in interventional cardiology, however, the CorPath GRX was recently approved by the FDA for peripheral vascular and extracranial interventions. The authors aimed to evaluate the operational learning curve for robot-assisted carotid artery stenting over a period of 19 months at a single institution. METHODS: A retrospective analysis of a prospectively maintained database was conducted, and 14 consecutive patients who underwent robot-assisted carotid artery stenting from December 2019 to June 2021 were identified. The metrics for proficiency were the total fluoroscopy and procedure times, contrast volume used, and radiation dose. To evaluate operator progress, the patients were divided into 3 groups of 5, 4, and 5 patients based on the study period. RESULTS: A total of 14 patients were included. All patients received balloon angioplasty and stent placement. The median degree of stenosis was 95%. Ten patients (71%) were treated via the transradial approach and 4 patients (29%) via the transfemoral approach, with no procedural complications. The median contrast volume used was 80 mL, and the median radiation dose was 38,978.5 mGy/cm2. The overall median fluoroscopy and procedure times were 24.6 minutes and 70.5 minutes, respectively. Subgroup analysis showed a significant decrease in these times, from 32 minutes and 86 minutes, respectively, in group 1 to 21.9 minutes and 62 minutes, respectively, in group 3 (p = 0.002 and p = 0.008, respectively). CONCLUSIONS: Robot-assisted carotid artery stenting was found to be safe and effective, and the learning curve for robotic procedures was overcome within a short period of time at a high-volume cerebrovascular center.

Lessons Learned After 760 Neurointerventions via the Upper Extremity Vasculature: Pearls and Pitfalls.

BACKGROUND: The radial approach has been gaining more widespread use by neurointerventionalists fueled by data from the cardiology literature showing better safety and overall reduced morbidity. OBJECTIVE: To present our institution's experience with the radial approach for neuroendovascular interventions in 614 consecutive patients who underwent a cumulative of 760 procedures. METHODS: A retrospective analysis was performed and identified neuroendovascular procedures performed via the upper extremity vasculature access site. RESULTS: Amongst 760 procedures, 34.2% (260) were therapeutic, and 65.7% (500) were nontherapeutic angiograms. Access sites were 71.5% (544) via a conventional radial artery, 27.8% (211) via a distal radial artery, 0.5% (4) via an ulnar artery, and 0.1% (1) via the brachial artery. Most of the procedures (96.9%) were performed via the right-sided (737), 2.9% (22) via the left-sided, and 0.1% (1) via a bilateral approach. Major access site complications occurred at a rate of 0.9% (7). The rate of transfemoral conversion was 4.7% (36). There was a statistically higher incidence of transfemoral conversion when repeat procedures were performed using the same access site. Also, there was no significant difference between nontherapeutic procedures performed using the right and left radial access, and conventional versus distal radial access. Procedural metrics improved after completion of 14 procedures, indicating a learning curve that should be surpassed by operators to reach optimal outcomes. CONCLUSION: Radial artery catheterization is a safe and effective means of carrying out a wide range of neuroendovascular procedures associated with excellent clinical outcomes and an overall low rate of periprocedural complications.

Experience With Ventriculoperitoneal and Lumboperitoneal Shunting for the Treatment of Idiopathic Intracranial Hypertension: A Single Institution Series.

BACKGROUND: CSF shunting is among the most widely utilized interventions in patients with idiopathic intracranial hypertension (IIH). Ventriculoperitoneal shunting (VPS) and lumboperitoneal shunting (LPS) are 2 possible treatment modalities. OBJECTIVE: To evaluate and compare complications, malfunction, infection, and revision rates associated with VPS compared to LPS. METHODS: Electronic medical records were reviewed to identify baseline and treatment characteristics for patients diagnosed with IIH treated with VPS or LPS. RESULTS: A total of 163 patients treated with either VPS (74.2%) or LPS (25.8%) were identified. The mean follow-up was 35 mo. Shunt revision was required in 40.9% of patients. There was a nonsignificant higher rate of revision with LPS (52.4%) than VPS (36.4%, P = .07). In multivariate analysis, increasing patient age was associated with higher odds of shunt revision (P = .04). LPS had higher odds of shunt revision, yet this association was not significant (P = .06). Shunt malfunction was the main indication for revision occurring in 32.7%, with a significantly higher rate with LPS than VPS (P = .03). In total, 15 patients had shunt infection (9.4% VPS vs 12.2% LPS P = .50). The only significant predictor of procedural infection was the increasing number of revisions (P = .02). CONCLUSION: The incidence of shunt revision was 40.9%, with increasing patient age as the sole predictor of shunt revision. The incidence of shunt malfunction was significantly higher in patients undergoing LPS, while there was no significant difference in the incidence of shunt infection between the 2 modalities.

Early experience with a novel 088 long sheath in transradial neurointerventions.

BACKGROUND: Transradial access (TRA) for neuroendovascular procedures has several clear benefits compared to transfemoral access. In this study, we report our initial experience with neuroendovascular procedures performed via transradial access using the novel Ballast 088 long sheath. METHODS: We conducted a retrospective analysis and identified 91 consecutive patients who underwent neuroendovascular procedures via TRA using the Ballast 088 long sheath. Data collection was performed on indication for procedure, number of vessels selectively catheterized, fluoroscopy time, procedure duration, radiation exposure, failure of radial access and conversion to transfemoral access, periprocedural complications, and procedural outcomes. RESULTS: Amongst 91 patients, the average age was 65.5 years ± 14.2 with 45 (49.5 %) female patients. 25 (27.5 %) patients underwent aneurysm treatment, 2 (2.2 %) AVM/AVF embolization, 28 (30.8 %) intracranial or extracranial stenting, 31 (34.1 %) stroke treatment, and 5 (5.5 %) underwent diagnostic angiogram. The mean number of target vessels catheterized was 1.07 ± 0.25, the mean procedure duration (minutes) was 96.5 ± 57.2, mean fluoroscopy time (minutes) was 21.9 ± 14.2, mean contrast dose (ml) was 112.7 ± 66.7, and mean radiation exposure (Gycm2) was 54.82 ± 41.37. The success rate of target vessel catheterization was 100 %. There were no complications resulting in long term sequelae. Access complications occurred in 1 (1.1 %) patients. Transfemoral conversion was required in 3 (3.3 %) patients. CONCLUSIONS: The Ballast 088 long sheath is safe and effective for TRA in neuroendovascular procedures with a low rate of complications and conversion.

A comparative study of transradial versus transfemoral approach for flow diversion.

PURPOSE: Data in neurointerventional literature is extremely limited regarding the safety and efficacy of flow diversion using transradial access (TRA). We aim to demonstrate the safety and efficacy of intracranial aneurysm treatment with the Pipeline Embolization Device (PED) using TRA compared to transfemoral access (TFA). METHODS: We conducted a retrospective analysis of a prospectively maintained database and identified 79 consecutive patients who underwent neuroendovascular embolization for cerebral aneurysms using the PED from April 2018 through October 2019. Patients were divided into 2 groups: TRA (32 patients) and TFA (47 patients). A comparative analysis was performed between the two groups. RESULTS: There was no significant difference in postoperative intracranial hemorrhage (p>.99), symptomatic ischemic stroke (p=.512), access site complications (p=.268), or other complications (p=.512). However, there was a significant increase in overall complications (14.9% vs. 0.0%, p=.038) and procedure duration (71.4 min ± 31.2 vs. 58.5 ± 20.3, p=.018) in the TFA group. There was no significant difference in complete occlusion at latest follow-up (19/25, 76.0% vs. 35/40, 87.5%; p=.311), 6-month follow-up (17/23, 73.9% vs. 33/38, 86.8%; p=.303), or 12-month follow-up (8/8, 100.0% vs. 5/6, 83.3%; p=.429). There was also no significant difference in rate of retreatment (p>.99), morbidity (p=.512), mortality (p>.99), latest follow-up (p=.985), or loss of follow-up (p=.298). CONCLUSIONS: The feasibility and efficacy of flow diversion with the PED via TRA for the treatment of intracranial aneurysms is comparable to TFA. Widespread adoption of this approach may be facilitated by improvements in device navigation and manipulation via radial-specific engineering.

Comparison of Transradial vs Transfemoral Access in Neurovascular Fellowship Training: Overcoming the Learning Curve.

BACKGROUND: The transradial access (TRA) is rapidly gaining popularity for neuroendovascular procedures as there is strong evidence for its benefits compared to the traditional transfemoral access (TFA). However, the transition to TRA bears some challenges including optimization of the interventional suite set-up and workflow as well as its impact on fellowship training. OBJECTIVE: To compare the learning curves of TFA and TRA for diagnostic cerebral angiograms in neuroendovascular fellowship training. METHODS: We prospectively collected diagnostic angiogram procedural data on the performance of 2 neuroendovascular fellows with no prior endovascular experience who trained at our institution from July 2018 until June 2019. Metrics for operator proficiency were minutes of fluoroscopy time, procedure time, and volume of contrast used. RESULTS: A total of 293 diagnostic angiograms were included in the analysis. Of those, 57.7% were TRA and 42.3% were TFA. The median contrast dose was 60 cc, and the median radiation dose was 14 000 µGy. The overall complication rate was 1.4% consisting of 2 groin hematomas, 1 wrist hematoma, and 1 access-site infection using TFA. The crossover rate to TFA was 2.1%. Proficiency was achieved after 60 femoral and 95 radial cases based on fluoroscopy time, 52 femoral and 77 radial cases based on procedure time, and 53 femoral and 64 radial cases based on contrast volume. CONCLUSION: Our study demonstrates that the use of TRA can be safely incorporated into neuroendovascular training without causing an increase in complications or significantly prolonging procedure time or contrast use.

Feasibility and initial experience of left radial approach for diagnostic neuroangiography.

Neuroangiography has seen a recent shift from transfemoral to transradial access. In transradial neuroangiography, the right dominant hand is the main access used. However, the left side may be used specifically for left posterior circulation pathologies and when right access cannot be used. This study describes our initial experience with left radial access for diagnostic neuroangiography and assesses the feasibility and safety of this technique. We performed a retrospective review of a prospective database of consecutive patients between April 2018 and January 2020, and identified 20 patients whom a left radial access was used for neurovascular procedures. Left transradial neuroangiography was successful in all 20 patients and provided the sought diagnostic information; no patient required conversion to right radial or femoral access. Pathology consisted of anterior circulation aneurysms in 17 patients (85%), brain tumor in 1 patient (5%), and intracranial atherosclerosis disease involving the middle cerebral artery in 2 patients (10%). The left radial artery was accessed at the anatomic snuffbox in 18 patients (90%) and the wrist in 2 patients (10%). A single vessel was accessed in 7 (35%), two vessels in 8 (40%), three vessels in 4 (20%), and four vessels in 1 (5%). Catheterization was successful in 71% of the cases for the right internal carotid artery and in only 7.7% for the left internal carotid artery. There were no instances of radial artery spasm, radial artery occlusion, or procedural complications. Our initial experience found the left transradial access to be a potentially feasible approach for diagnostic neuroangiography even beyond the left vertebral artery. The approach is strongly favored by patients but has significant limitations compared with the right-sided approach.

Incidence and predictors of ophthalmic artery occlusion in intra-arterial chemotherapy for retinoblastoma.

BACKGROUND: Retinoblastoma is the most common primary intraocular malignancy in children. OBJECTIVE: To determine the incidence of ophthalmic artery (OA) occlusion in patients treated with selective ophthalmic artery catheterization (OAC) for chemotherapy infusion for retinoblastoma. Also, to evaluate technical, anatomical, tumorous, and patient-related factors that are predictors of OA occlusion. METHODS: A retrospective chart review was performed for patients diagnosed with intraocular retinoblastoma and managed with intra-arterial chemotherapy (IAC). RESULTS: The total study cohort included 208 retinoblastoma tumors of 208 eyes in 197 consecutive patients who underwent 688 attempted IAC infusions overall with a total of 624 successful OAC infusions. The total incidence of ophthalmic artery thrombosis was 11.1% (23/208). The numbers of successful OAC procedures before diagnosing OA occlusion were one OAC in six cases (27.3%), two in seven cases (31.8%), three in four cases (18.2%), four in one case (4.5%), five in two cases (9.1%), and six in one case (4.5%). CONCLUSIONS: Local factors relating to the chemotherapy and selective microcatheterization of the OA are essential factors in the development of OA thrombosis, as seen by the association of OA thrombosis with the frequency of IAC.

Endovascular Management of Complex Fenestration-Associated Aneurysms: A Single-Institution Retrospective Study and Review of Existing Techniques.

BACKGROUND: Aneurysms associated with fenestrations of intracranial arteries are exceptionally rare findings. Management strategies for these aneurysms are not well-defined, especially regarding endovascular treatment. We sought to investigate the strategies and feasibility of endovascular treatment approaches for various fenestration-associated intracranial aneurysms. METHODS: We performed a retrospective chart review of 2000 aneurysms treated endovascularly, identifying 8 aneurysms located at arterial fenestrations. The technical details and procedural outcomes were reviewed to identify common management approaches, technical nuances, and treatment outcomes. RESULTS: There were 3 (37.5%) aneurysms associated with fenestrations of the basilar artery or vertebrobasilar junction. All 3 were successfully treated with a previously undescribed coil-assisted flow-diversion technique, resulting in complete obliteration. Three (37.5%) aneurysms were associated with fenestrations of the anterior communicating artery. Of those, 2 were successfully treated with stent-assisted coil embolization and 1 with coil embolization alone. One (12.5%) aneurysm was associated with a fenestration of the paraclinoid internal carotid artery and 1 (12.5%) aneurysm found was at the takeoff of the posterior inferior cerebellar artery at a fenestration of the vertebral artery. Both were successfully treated with coil-assisted flow diversion. There were no permanent procedural complications. Major considerations for endovascular management of these aneurysms were the dominance of fenestration trunks, aneurysms arising from the fenestration apex or a fenestration limb, amenability to flow diversion, and anticipation of vascular remodeling. CONCLUSIONS: Fenestration-associated aneurysms are very rare. We have identified common factors to help guide decision-making for endovascular approaches and demonstrate successful aneurysm treatment using these methods.

The impact of the implementation of a mobile stroke unit on a stroke cohort.

BACKGROUND: Mobile stroke units (MSUs), specialized ambulances with a built-in computed tomography (CT) scanner and telemedicine connected stroke team, have been on the rise in recent years largely due to the 'time is brain' concept. We aim to report our initial experience since establishing our MSU, the first unit in the Tri-state area, and assess its impact on the stroke standards of care timeline. METHODS: We conducted a retrospective analysis of a prospectively maintained database of all MSU dispatched cases from August 2019 to March 2020. RESULTS: Of 195 MSU responses, 101 were treated and transported by the MSU. The mean time (hr:mm) of dispatch to scene arrival was 0:07+0:03, scene arrival to CT start was 0:10+0:03, CT start to teleneuro start was 0:05+0:03, teleneuro start to scene departure was 0:06+0:05, scene departure to hospital arrival was 0:12+0:06, and hospital arrival to arterial puncture was 2:59+1:01. The mean time of dispatch to arterial puncture was 3:34+1:02. The mean teleneuro consult duration was 0:04+0:02. The mean time of last know well (LKW) to tPA administration was 1:28+0:48 with 4 (57.1 %) patients receiving tPA within 60 min of LKW and 5 (71.4 %) patients receiving tPA within 90 min. The mean time of dispatch to tPA was 0:37+0:09 and scene arrival to tPA administration was 0:28+0:07. CONCLUSION: MSUs may expedite each step along the stroke standards of care. In theory, this should drastically improve functional outcomes. However, the impact on functional outcomes or reductions in stroke-related morbidity is still unknown.

Posterior circulation tandem occlusions: Classification and techniques.

BACKGROUND: Posterior circulation tandem occlusions are poorly characterized in current literature. Data regarding endovascular approaches and outcomes in this patient subgroup is extremely limited. METHODS: We conducted a retrospective analysis of a prospectively maintained database and identified 17 patients with posterior circulation tandem occlusions who underwent mechanical thrombectomy between 2014 and 2019. RESULTS: Of 17 patients with posterior circulation tandem occlusion, the mean age was 55.76 ± 11.8 with 35.3% female. The mean NIHSS score on presentation was 17.2 ± 9.2. Tissue plasminogen activator was administered in 7 (41.2%) patients, stent-retrievers alone were used in 2 (11.8%), aspiration catheters alone were used in 2 (11.8%), a combination was used 12 (70.6%), and a self-expandable stent in 5 (29.4%). The mean number of device passes was 2.24 ± 2.02, recanalization failure occurred in 4 (23.5%) patients, the mean time from stroke onset to puncture was 6.9 ± 2.4 h, and the mean time from puncture to recanalization was 59.3 ± 26.6 min. Postprocedural symptomatic ICH occurred in 1 (5.9 %) patient, periprocedural ICH/SAH occurred in 2 (11.8%), periprocedural distal emboli occurred in 0 (0%), periprocedural vessel dissection occurred in 1 (5.9%), and periprocedural vessel perforation occurred in 1 (5.9%) patient. TICI score>2b was achieved in 13 (76.5%) patients. An improvement in NIHSS>3 at discharge occurred in 10 (58.8%) patients, and good outcomes (mRS score < 2) occurred in 7 (41.2%). The mean length of stay was 11.6 ± 12.2 days, and the mortality rate was 41.2%. CONCLUSION: Endovascular intervention with mechanical thrombectomy is safe and feasible in patients with posterior circulation tandem occlusions.

Comparison of robotic-assisted carotid stenting and manual carotid stenting through the transradial approach.

OBJECTIVE: The objective of this study was to demonstrate the feasibility and safety of CorPath GRX robotic-assisted (RA) transradial (TR) carotid artery stenting (CAS) compared with manual TR CAS. METHODS: The authors conducted a retrospective analysis of a prospectively maintained database and identified 13 consecutive patients who underwent TR CAS from June 2019 through February 2020. Patients were divided into 2 groups: RA (6 patients) and manual (7 patients). RESULTS: Among 6 patients in the RA group with a mean age of 70.0 ± 7.2 years, technical success was achieved in all 6 (100%) procedures; there were no technical or access-site complications and no catheter exchanges. Transfemoral conversion was required in 1 (16.7%) case due to a tortuous aortic arch. There were no perioperative complications, including myocardial infarction, stroke, and mortality. The mean procedure duration was significantly longer in the RA group (85.0 ± 14.3 minutes [95% CI 69.9-100.0] vs 61.2 ± 17.5 minutes [95% CI 45.0-77.4], p = 0.0231). There was no significant difference in baseline characteristics, fluoroscopy time, contrast dose, radiation exposure, catheter exchanges, technical success, transfemoral conversion, technical or access-site complications, myocardial infarction, stroke, other complications, or mortality. CONCLUSIONS: The authors' results suggest that RA TR CAS is feasible, safe, and effective. Neurovascular-specific engineering and software modifications are needed prior to complete remote control. Remote control has important implications regarding patient access to lifesaving procedures for conditions such as stroke and aneurysm rupture as well as operative precision. Future clinical investigations among larger cohorts are needed to demonstrate reliable performance and patient benefit.

Transradial approach for diagnostic cerebral angiograms in the elderly: a comparative observational study.

BACKGROUND: The transradial approach (TRA) reduces mortality, morbidity, access site complications, hospital cost, and length of stay while maximizing patient satisfaction. We aimed to assess the technical success and safety of TRA for elderly patients (aged ≥75 years). METHODS: A retrospective chart review and comparative analysis was performed for elderly patients undergoing a diagnostic cerebral angiogram performed via TRA versus transfemoral approach (TFA). Also, a second comparative analysis was performed among the TRA cohort between elderly patients and their younger counterparts. RESULTS: Comparative analysis in the elderly (TRA vs TFA) showed no significant differences for contrast dose per vessel (43.7 vs 34.6 mL, P=0.106), fluoroscopy time per vessel (5.7 vs 5.2 min, P=0.849), procedure duration (59.8 vs 65.2 min, P=0.057), conversion rate (5.8% vs 2.9%, P=0.650), and access site complications (2.3% vs 2.9%, P=1.00). Radiation exposure per vessel (18.9 vs 51.9 Gy cm2, P=0.001) was significantly lower in the elderly TRA group.The second comparison (TRA in elderly vs TRA in the young) showed no significant differences for contrast dose per vessel (43.7 vs 37.8 mL, P=0.185), radiation exposure per vessel (18.9 vs 16.5 Gy cm2, P=0.507), procedure duration (59.8 vs 58.3 min, P=0.788), access site complication (2.3% vs 1.7%, P=0.55), and conversation rate (5.8% vs 1.8%, P=0.092). A trend for prolonged fluoroscopy time per vessel (5.7 vs 4.7 min, P=0.050) was observed in the elderly TRA group. CONCLUSIONS: TRA is a technically feasible and safe option for diagnostic neurointerventional procedures in the elderly. Our small elderly cohort was not powered enough to show a significant difference in terms of access site complications between TRA and TFA.