Protrieve Sheath embolic protection during venous thrombectomy: early experience in seventeen patients.

PURPOSE: The Protrieve Sheath (Inari Medical; Irvine, CA) is designed for embolic protection during venous thrombectomy. This report describes experience with its use. MATERIALS AND METHODS: Between November 2022 and December 2023 (13 months), seventeen patients, including nine (52.9%) females and eight (47.1%) males (mean age 58.8 ± 13.3 years, range 37-81 years), underwent deep venous thrombectomy following the Protrieve Sheath placement for embolic protection. Gender, age, presenting symptoms, procedural indications, obstructed venous segments, the Protrieve Sheath access and deployment sites, thrombectomy devices utilized, need for stent reconstruction, technical success, clinical success, adverse events (the Protrieve Sheath maldeployment or clinically significant embolic events), removed thrombi analyses, and mortality were recorded. Technical success was defined as successful deployment of the Protrieve Sheath funnel central to the thrombectomy site. Clinical success was defined as improvement in presenting venous occlusive symptoms without procedure-related venous thromboembolism. RESULTS: The most common presenting symptom was extremity swelling (n = 15; 88.2%). Nine (52.9%) patients had malignant and eight (47.1%) had benign etiologies of venous obstruction. Obstructed venous segments included the inferior vena cava (IVC) and lower extremity (n = 9; 52.9%), isolated lower extremity (n = 4; 23.5%), isolated IVC (n = 2; 11.8%), thoracic central veins and superior vena cava (n = 1; 5.9%), and isolated thoracic central vein (n = 1; 5.9%). The Protrieve Sheath access sites included the right internal jugular vein (n = 15; 88.2%) for IVC and lower extremity obstructions and the right common femoral vein (n = 2; 11.8%) for thoracic central vein and superior vena cava obstructions. The Protrieve sheath funnel deployment locations included intrahepatic IVC in 13 patients (n = 13; 76.5%), suprarenal IVC in two (n = 2; 11.8%), and inferior cavoatrial junction in two (n = 2; 11.8%). Thrombectomy devices used included the ClotTriever System (Inari Medical) (n = 15; 88.2%), the InThrill Thrombectomy System (Inari Medical) (n = 4; 23.5%), the FlowTriever System (Inari Medical) (n = 2; 11.8%), the Lightning Flash 16 Aspiration System (Penumbra; Salt Lake City, UT) (n = 2; 11.8%), the Cleaner Rotational Thrombectomy System (Argon; Plano, TX) (n = 1; 5.9%), and the RevCore Thrombectomy System (Inari Medical) (n = 1; 5.9%). Ten (58.8%) patients required stent reconstruction following thrombectomy. Technical success was achieved in all patients. Clinical success was achieved in 16 (94.1%) patients. No immediate adverse events, including the Protrieve Sheath maldeployment or clinically significant embolic events, occurred. CONCLUSION: Use of the Protrieve Sheath during large-bore venous mechanical thrombectomy resulted in favorable technical and clinical outcomes without device-related adverse events or clinically significant thromboembolic events.

Sticky Science: Using Complex Coacervate Adhesives for Biomedical Applications.

Tissue adhesives are used for various medical applications, including wound closure, bleeding control, and bone healing. Currently available options often show weak adhesion or cause adverse effects. Recently, there has been an increasing interest in complex coacervates as medical adhesives. Complex coacervates are formed by mixing oppositely charged macromolecules that associate and undergo liquid-liquid phase separation, in which the dense bottom phase is the complex coacervate. Complex coacervates are strong and often biocompatible, and show strong underwater adhesion. The properties of the resulting materials are tunable by intrinsic factors such as polymer chemistry, molecular weight, charge density, and topology of the macromolecules, as well as extrinsic factors such as temperature, pH, and salt concentration. Therefore, complex coacervates are interesting new candidates for medical adhesives. In this review, it is described how complex coacervates form and how different factors influence their behavior. Next, an overview of recent studies on complex coacervates in the context of medical adhesives is presented. The application of complex coacervates as hemostatic or embolic agents, skin or bone repair adhesives, and soft tissue sealants is discussed. Lastly, additional possibilities for utilizing these materials in the future are discussed.

Cerebral Embolic Protection: Is There a Benefit for Left Atrial and Mitral Valve Procedures?

PURPOSE OF REVIEW: This review aims to highlight the current evidence on the use of cerebral embolic protection devices (CEPD) in left atrial and transcatheter mitral valve procedures. It also aims to summarize the antithrombotic management of patients undergoing such procedures. RECENT FINDINGS: Ischemic stroke is one of the most devastating complications of structural heart procedures. The manifestation of periprocedural stroke can range from asymptomatic and detectable only through brain imaging to major stroke with neurological deficits. CEP devices were initially developed to mitigate the risk of stroke associated with transcatheter aortic valve replacement (TAVR). However, the efficacy of such devices during different cardiac interventions is yet to be fully demonstrated, especially in left atrial appendage closure (LAAO), and mitral valve interventions. Few studies demonstrated that the risk of periprocedural strokes after LAAO and mitral valve interventions is not negligible and is highest during the periprocedural period and then falls. The majority of patients undergoing those procedures have cerebral ischemic injuries detected on diffusion-weighted magnetic resonance imaging (DW-MRI). Moreover, a reasonable number of those patients had debris embolization on the filters of the CEPD. Pharmacological therapy with antithrombotic agents before, during, or after structural heart interventions is crucial and should be tailored to each patient's risk of bleeding and ischemia. Close monitoring that includes a full neurological assessment and frequent follow-up visits with cardiac echocardiography are important. The risk of periprocedural stroke in left atrial and transcatheter mitral valve procedures is not negligible. Pharmacological therapy with antithrombotic agents before, during, or after structural heart interventions is important to mitigate the risk of stroke, especially the long-term risk. More prospective studies are needed to assess the efficacy of CEPD in such procedures.

Super-selective renal artery embolization (SRAE) for iatrogenic and traumatic renal hemorrhage.

PURPOSE: To present the radiological and clinical outcomes of super-selective transcatheter renal artery embolization in patients with renal injury hemorrhage, and share our experience. METHODS: 43 patients with renal injury hemorrhage who underwent 46 SRAEs were enrolled in this retrospective review study. Records, images, and outcomes were reviewed. The individual embolic method and its observed effects were investigated. RESULTS: Angiography showed free extravasation in 25 angiograms, pseudoaneurysm in 15 angiograms, and arteriovenous fistulas in 1 angiogram. Most patients achieved initial clinical success (38/43, 88.4%), and 41 patients achieved final clinical success (41/43, 95.3%). 9/11 patients who adopted empirical embolization achieved initial clinical success (81.8%). In our study, the combination of PVA particles and micro-coils has emerged as the most commonly utilized material combination (24/46, 52.2%). Significant differences in hemoglobin levels were observed before and after the embolization procedure (p = 0.026, 95%CI: 1.03-15.54). Post-embolization clinical follow-up showed no evidence of recurrent hematuria, progression of hematoma, hypertension, and no reflux of the embolic agent. CONCLUSION: Though SRAE showed satisfactory results across a broad range of renal injury hemorrhage, there are still some aspects that need attention: (1) Surgical procedure should be understood, including the surgical site, access routes, and placement of implants, such as double-J stents. (2) In cases where identifying the bleeding point proves challenging, consider the possibility of an accessory renal artery. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2400085050, Registration Date: 30 May 2024, retrospectively, non-randomized.

A Rare Case of Ruptured Distal Posterior Cerebral Artery Aneurysm Followed by Middle Cerebral Artery Occlusion due to Delayed Diagnosis of Infective Endocarditis.

A 31-year-old female presented to our hospital with sudden headache and altered consciousness. Computed tomography showed left acute subdural hematoma, and digital subtraction angiography revealed a small aneurysm on the left distal posterior cerebral artery. Coil embolization was conducted, and the patient was discharged with no neurological deficits. However, two weeks later, she presented with complete left hemiplegia and with the National Institutes of Health Stroke Scale of 20. Magnetic resonance angiography showed the occlusion of right middle cerebral artery, and the Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Score was four. Mechanical thrombectomy was conducted. Complete recanalization was achieved, and the patient recovered favorably. Although she showed no symptoms of infection such as fever throughout the treatment of aneurysm and thrombectomy, her blood culture was positive for streptococcus mitis. Furthermore, the thrombus retrieved by thrombectomy showed bacterial mass, and transesophageal echocardiography (TEE) showed vegetation on the mitral valve that could not be detected by transthoracic echocardiography. Therefore, the patient was diagnosed with infective endocarditis (IE). She was administered penicillin for 6 weeks and was discharged with no neurological deficits. When treating young patients with small aneurysms in rare locations, IE should be suspected, and blood culture and TEE should be conducted, even when there are no obvious symptoms of systemic infection.

Mechanical investigation of a Tandem embolization-visualization system for minimally invasive procedures.

Transcatheter arterial embolization is a minimally invasive intervention process in which the blood supply to a tumor or an abnormal area of tissue is blocked. One of the most commonly used embolic agents in clinics is microsphere (MS). In order to understand the flow behavior of microspheres in arteries, it is essential to study their mechanical properties systematically. In this work, calcium-alginate MSs with varying calcium concentrations were synthesized using a coaxial airflow method. Indocyanine green (ICG) was added as a fluorescent dye. The effect of ICG concentration change on microspheres was investigated by studying morphology, imageability, rheology, and swelling behavior. Then the effect of calcium chloride concentration change on microspheres was studied by conducting rheological tests, atomic force microscopy tests, hemolysis assay, and thrombogenicity assay. Results showed that microspheres with higher ICG concentrations have longer lasting fluorescence and lower storage modulus (G'). Higher concentrations of calcium chloride led to higher G', while the local Young's modulus obtained by AFM test was not significantly affected. The MSs with and without ICG showed good hemocompatibility and thrombogenicity.

Magnetic resonance imaging features and stroke etiology of ischemic stroke in essential thrombocythemia.

BACKGROUND: Various essential thrombocythemia (ET)-related stroke mechanisms have been proposed, including microcirculatory disturbance due to coagulopathy, vasculitis, and embolism due to thrombus formation in large vessels. However, the stroke mechanism in ET remains largely unexplored. The purpose of this study was to evaluate magnetic resonance image (MRI) features of ischemic stroke in ET and determine the potential stroke mechanism. METHODS: We retrospectively collected data from 21 acute ischemic stroke patients with ET who were admitted to two stroke centers between 2010 and 2023. ET was diagnosed according to the World Health Organization criteria. We evaluated MRI features including the diffusion-weighted image (DWI) lesion pattern, and the presence of hemorrhagic transformation and intracranial artery steno-occlusive lesion, as well as other etiological workup results. RESULTS: Of 21 patients, 20 exhibited multiple ischemic lesions on DWI, mainly within a single vascular territory. Cortical infarcts were observed in 19 patients. Hemorrhagic transformation occurred in 15 patients. Additionally, 15 patients had intracranial steno-occlusive arteries, which regressed to normal in 11 patients during follow-up. Out of all patients, only 2 had potential causes of stroke other than ET (1 with atrial fibrillation and 1 with intracranial atherosclerotic stenosis). The remaining 19 patients had ET as the only identified potential cause. CONCLUSIONS: MRI features, including DWI lesion pattern in ischemic stroke patients with ET, suggested embolic etiology despite the absence of major embolic sources. Intra-arterial thrombus appears to be part of the stroke mechanism related to ET and may contribute to ischemic stroke in ET.

Cerebral Embolic Protection Devices: Are There Any Indications in Transcatheter Aortic Valve Replacement?

Stroke following transcatheter aortic valve replacement (TAVR) is a significant and life-threatening adverse event. The vast majority of these incidents occur during the TAVR procedure or within the first 24 h following TAVR, with a notable prevalence of cerebral embolic events. In response to this concern, cerebral embolic protection devices (CEPDs) have been designed to mitigate the risk of peri-procedural ischemic stroke during TAVR. The primary objective of CEPDs is to diminish the intraprocedural burden associated with new silent ischemic brain injuries. Despite the development of several CEPDs, their clinical efficacy remains uncertain. In this review, we delve into a comprehensive analysis of the utilization of CEPDs in patients undergoing TAVR, exploring insights from the existing literature. Additionally, we aim to present future perspectives and discuss the clinical implications associated with the incorporation of CEPDs in TAVR procedures.

Impact of multidisciplinary Endocarditis Team on management of infective endocarditis.

Infective Endocarditis (IE) is a complex, life-threatening disease. The aim of the present study was to evaluate the impact of the Endocarditis-Team on management of IE. This observational study conducted at a university hospital (2015‒22), included adult patients with IE. The study period was divided in two periods: before (pre-Endocarditis-Team; pre-ET) and after the establishment of the Endocarditis-Team (post-Endocarditis-Team; post-ET) on January 2018. Among 505 IE episodes (187 in pre-Endocarditis-Team, 318 in post-ET period), 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography was more commonly used in post-ET period (14 % vs. 28 %; p < 0.001). Overall, thirty-day and one-year mortality were 14 % and 27 %, respectively; no difference was observed between the two periods. In post-ET period, the administration of 4-weeks, rather than 6-weeks, of intravenous antimicrobial treatment was higher than in the post-ET period (15 % vs. 45 %; p < 0.001). Indication for surgery was present in 115 (61 %) patients in pre-ET and in 153 (48 %) in the post-ET period. In post-ET period, among patients with indication, valve surgery was more frequently performed (66 % vs. 78 %; p = 0.038). Such difference was due to a higher acceptance of operative indication by the cardiac surgeon (69 % vs. 94 %; p = 0.013). The observed increase in number of patients benefiting from cardiac surgery in the post-ET period led to a decrease of subsequent embolic events, since among patients with operative indication (n = 268), new embolic events after the establishment of the indication were more common in the pre-ET period compared to post-ET (23 % vs. 12 %; p = 0.033). After the implementation of the multidisciplinary Endocarditis-Team we observed several improvements in the general management of IE patients.

Development of a Short-Term Embolic Agent Based on Cilastatin for Articular Microvessels.

Background and Objectives: This study aimed to develop an embolic agent with short-term embolic effects using cilastatin as the basic material. Materials and Methods: The particle size distribution of 25 mg cilastatin-based short-term embolic agents was evaluated microscopically under three different mixing conditions. A total of thirty-six healthy male Sprague Dawley rats were divided into four groups. Each group of six rats was injected once into the tail artery with 0.4 mL each of (A) Cilastatin + D-Mannitol Mixture, (B) Iohexol, (C) Prepenem, and (D) embolization promoter (EGgel). Results: A visual inspection of the tail appearance of rats in each group was performed at 0, 3, 7, 15, and 21 days. At weeks 1 and 3, three rats per group were euthanized, and histopathological analyses were performed on the specimens obtained from each group. No significant differences were observed on day 7, but mild inflammation was observed in Group (D) on day 15. Histopathological inflammation scoring of tail central artery embolization was performed using a six-point scale (from 0 = absent to 5 = marked inflammation). Three groups were formed consisting of six male New Zealand white rabbits each: control, positive control, and test groups. The control group received an Iohexol injection (rabbits: 0.8 mL). The positive control and experimental groups were injected with prepenem and cilastatin/D-mannitol compound, respectively (0.8 mL), and vascular angiography was performed. The order of occlusion progression after embolization was as follows: test group, positive control group, and control group. Conclusions: We developed a cilastatin/D-mannitol compound that exhibits characteristics of short-term embolization by utilizing the pharmacokinetic properties of cilastatin and the crystalline material D-mannitol. We evaluated its particle size distribution microscopically, conducted histopathological evaluation including inflammation via animal experiments, and assessed the embolization effect.

Successful TAVR for a Patient with Bicuspid Aortic Valve Stenosis and Previous Type A Aortic Dissection.

Whether transfemoral transcatheter aortic valve replacement (TAVR) can be accomplished in patients with a bicuspid aortic valve (AV) and previous type A aortic dissection remains rarely addressed. We report such a case in whom transfemoral TAVR was smoothly performed employing an extraordinary long sheath to bypass the dissected aortic segment, yet at the cost of perioperative left temporoparietal infarction owing to no suitable cerebral embolic protection device available in the presence of a remaining dissection in the aortic arch. Thus, for such patients, transfemoral TAVR is still feasible but novel embolic protection devices of distinct designs should be developed to avoid perioperative cerebral embolism.

Overview and Future Direction of Embolic Stroke of Undetermined Source from the Insights of CHALLENGE ESUS/CS Registry.

Cryptogenic stroke (CS) accounts for approximately one-fourth of acute ischemic strokes, with most cases derived from embolic etiologies. In 2014, embolic stroke of undetermined source (ESUS) was advocated and the efficacy of anticoagulant therapy was anticipated. However, 3 large-scale clinical trials failed to demonstrate the superiority of direct oral anticoagulants (DOACs) over aspirin, potentially due to the heterogeneous and diverse pathologies of ESUS, including paroxysmal atrial fibrillation (AF), arteriogenic sources such as nonstenotic carotid plaque and aortic complicated lesion (ACL), patent foramen oval (PFO), and nonbacterial thrombotic endocarditis (NBTE) related to active cancer.Transesophageal echocardiography (TEE) is one of the most effective imaging modalities for assessing embolic sources in ESUS and CS. The Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke (CHALLENGE ESUS/CS) registry is a multicenter registry that enrolled consecutive patients with CS who underwent TEE at 8 hospitals in Japan between April 2014 and December 2016. Their mean age was 68.7±12.8 years, and 455 patients (67.2%) were male. The median National Institutes of Health Stroke Scale (NIHSS) score was 2. Since 7 analyses have been conducted from each institution to date, novel and significant insights regarding embolic origins and pathophysiologies of ESUS and CS were elucidated from this multicenter registry. This review discusses the diagnosis and treatment of ESUS and CS, tracing their past and future directions. Meaningful insights from the CHALLENGE ESUS/CS registry are also referenced and analyzed.

Impact of stress hyperglycemia on outcomes in patients with large ischemic stroke.

BACKGROUND: Clinical evidence of the potential influence of stress hyperglycemia ratio (SHR) for patients with large ischemic stroke whether or not receiving endovascular therapy is not clear. METHODS: This study was a subanalysis of a prospective, multicenter registry, and included 745 patients with large ischemic stroke across 38 centers in China. A total of 427 patients were included in this study, with 285 received endovascular therapy (EVT) and 142 received standard medical therapy (SMT). SHR was defined as glucose (mmol/L)/(1.59 × HbA1C)-2.59. The primary outcome was a moderate neurological outcome (modified Rankin Scale (mRS) score ≤3) at 90 days. RESULTS: A significant interaction was observed between SHR and whether received EVT (p=0.017). Among patients who received EVT (adjusted OR (aOR) 0.46; 95% CI 0.23 to 0.92; p=0.029), patients in the highest tertile of SHR were significantly less likely to achieve a moderate neurological outcome at 90 days compared with those in the lowest tertile. However, this association was not observed in patients receiving SMT (aOR 2.46; 95% CI 0.74 to 8.21; p=0.142). EVT patients with higher SHR had a significantly higher incidence of symptomatic intracranial hemorrhage compared with lower SHR (aOR 3.29; 95% CI 1.08 to 10.06; p=0.036), while such an association was not observed in the SMT group (aOR 1.52; 95% CI 0.56 to 4.12; p=0.410). CONCLUSIONS: In patients with large ischemic stroke treated with EVT, SHR is associated with a reduced likelihood of achieving a moderate neurological outcome, as well as an increased risk of symptomatic intracranial hemorrhage. TRIAL REGISTRATION NUMBER: ChiCTR2100051664.

Investigating the Role of Invasive Streptococcus Constellatus Infection in Severe Systemic Disease Manifestations: A Case Report.

We hope to add to the literature evidence regarding the increasing morbidity associated with an invasive infection by a normal body commensal, Streptococcus constellatus (S. constellatus). An increasing amount of literature documentation of intra- and extracranial disease manifestations following a systemic infection by this micro-organism is noted. We describe the findings of severe, necrotizing right lung disease and possible septic brain emboli in a 54-year-old gentleman in whom microbiological investigations suggest Streptococcal pneumonia, S. constellatus, and mixed anaerobes as possible culprit micro-organisms causing his severe disease state.

Higher intracranial positioning of an 8 Fr guide catheter improves efficacy of aspiration thrombectomy in large vessel occlusion stroke.

BACKGROUND: Higher positioning of a large bore guide catheter during endovascular thrombectomy (EVT) is hypothesized to potentially improve thrombectomy success. OBJECTIVE: To evaluate the safety and efficacy of intracranial guide catheter placement during EVT using a multicenter database. METHODS: We reviewed data on consecutive patients undergoing EVT for anterior circulation large vessel occlusion (LVO) at three comprehensive stroke centers between October 2019 and December 2022. Participants were allocated to one of two cohorts: intracranial (n=141)-guide catheter tip positioned in the petrous carotid or further distal; and control (n=285)-guide catheter tip below the petrous carotid. Primary outcome was excellent reperfusion (Thrombolysis in Cerebral Ischemia (TICI) 2c or better), first pass effect (TICI 2c or better after one pass), and arterial access to final reperfusion time. The unpaired t-test, Mann-Whitney U test, and Fisher's exact test were used to compare themeans, medians and proportions of the two groups, respectively. P values & lt;0.05 were considered statistically significant two cohorts. RESULTS: A total of 426 patients were included in the analysis. Patients with guide catheter location in the petrous segment or further distal had a significantly higher first-pass effect (111/284, 39.1% vs 37/141, 26.2%, P=0.009). There was no significant difference in final excellent recanalization rates between groups (202/285, 70.9% vs 92/141, 65.2%, P=0.266). Furthermore, intracranial positioning of the guide catheter was associated with significantly shorter time to final recanalization (median 21.0 (13.0-38.0) min vs 30.0 (17.0-48.0) min, P<0.001). CONCLUSION: Positioning a large bore guide catheter in the petrous segment or further distal resulted in a significantly higher rate of first pass effect, faster procedural times, and equivalent final excellent reperfusion rates compared with more proximal guide catheter placement for patients with anterior circulation LVO.

Oral Contraceptive Pills as a Potential Cause of Wallenberg Syndrome: A Mysterious Case.

Wallenberg syndrome, also known as lateral medullary syndrome, is a rare neurological condition caused by an ischemic stroke in the posterior inferior cerebellar artery (PICA) territory of the brainstem. Here, we present a case of Wallenberg syndrome in a relatively healthy 37-year-old woman with no known risk factors besides a history of long-term oral contraceptive pill (OCP) use without prior adverse effects. The patient presented with acute onset headache that worsened in bright light, left-sided lightheadedness, dizziness, blurry vision, and non-bloody, non-bilious emesis. A neurological exam revealed left facial numbness and left upper extremity numbness; however, strength was intact in all extremities. An MRI revealed an acute ischemic infarct in the left PICA distribution, consistent with Wallenberg syndrome. While the initial thought was that the patient's OCP use contributed to this stroke, it has been deduced that the risk of stroke with current formulations of OCPs is insignificant compared to women who do not take any OCPs. This case highlights the importance of reconsidering OCPs as the cause of stroke in young, healthy patients without significant risk factors and considering reclassification as an embolic stroke of undetermined source (ESUS).

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.

Prevalence of Neurovascular Microemboli After Transcatheter Aortic Valve Replacement.

Background: Neurolotic sequelae after transcatheter aortic valve replacement (TAVR) can cause significant morbidity and mortality. Transcranial Doppler (TCD) imaging can show real-time high intensity transient signals (HITS), which reflect active microembolization. Although it is well known that intraprocedural microembolism occurs, it is not known if this embolic phenomenon continues in the postprocedural period. We investigated whether microemboli occur post-TAVR and whether we could determine any clinical, procedural, or echocardiographic predictors. Methods: We evaluated HITS in 51 consecutive patients undergoing unprotected TAVR with low-, intermediate-, or high-risk Society of Thoracic Surgeons score. Patients were excluded if they did not have temporal windows for insonation of the middle cerebral artery or if they were not willing to participate. Primary outcomes of HITS 24 hours post-TAVR were observed using a Philips iU22 TCD. TCD was performed at 3 time points (pre-, peri-, and post-TAVR) for each patient, before, during, and 24 hours postprocedure. Results: While no HITS were detected in any of the patients preoperatively, all patients had HITS during the procedure. Interestingly, 56.8% had HITS 24 hours post-TAVR. One patient with HITS post-TAVR had a stroke 48 hours after TAVR. Conclusion: We observed a high prevalence of microemboli 24 hours post-TAVR. None of the predictors for intraprocedural microembolism seemed to play an important role for post-TAVR microemboli.

Outcomes and Predictors of Stroke After Transcatheter Aortic Valve Replacement in the Cerebral Protection Device Era.

BACKGROUND: Studies have shown inconclusive results on the effectiveness of cerebral protection devices (CPDs) with transcatheter aortic valve replacement. We aimed to analyze the national statistics on stroke and other outcomes with CPD use. METHODS AND RESULTS: The Nationwide Readmissions Database (2017-2020) was queried to obtain data on patients undergoing transcatheter aortic valve replacement. Outcomes were compared between patients with a CPD and patients without a CPD. Of 271 804 patients undergoing transcatheter aortic valve replacement, CPD was used in 7.3% of patients. In a multivariable logistic regression analysis, CPD use was not associated with lower overall stroke rates (1.6% versus 1.9% without CPD; odds ratio, 0.95 [95% CI, 0.84-1.07]; P=0.364), but it was significantly associated with lower major stroke rates (1.2% versus 1.5% without CPD; odds ratio, 0.85 [95% CI, 0.74-0.98]; P=0.02). Patients with a CPD also had a shorter length of stay, higher routine discharges to home/self-care (74.9% versus 70.6%), and lower mortality rates (0.7% versus 1.3%). The 30-day (9.6% versus 11.7%) and 180-day (24.6% versus 28.2%) readmission rates were significantly lower in the CPD cohort. Among patients who developed stroke, patients with a CPD had more frequent routine discharges. Prior valve surgery was associated with the highest risk of overall and major stroke. CONCLUSIONS: CPD use during transcatheter aortic valve replacement was not independently associated with a lower risk of overall stroke but was associated with a lower risk of major stroke in a multivariable model. Data from future randomized trials that may offset any potential confounders in our study are required to help identify patients who would benefit from the use of these devices.