Telescoping Dual Covered Stent Graft Construct for Endovascular Treatment of a Giant Extracranial Carotid Artery Pseudoaneurysm.

Large pseudoaneurysms which compress the parent vessel are challenging lesions to successfully treat with endovascular therapy. We describe the endovascular treatment of a giant extracranial carotid artery (ECCA) pseudoaneurysm resulting in substantial mass effect on the common carotid artery (CCA) bifurcation using a telescoping dual covered stent graft construct. A 56-year-old male was diagnosed with an 8.5 cm × 13 cm pseudoaneurysm arising from the left CCA bifurcation, which was causing luminal narrowing of the CCA and proximal internal carotid artery (ICA). The patient underwent endovascular intervention, during which a balloon-expandable covered stent was deployed within a heparin-bonded covered stent, such that the overall construct spanned from the CCA to the lower cervical ICA. The employment of a telescoping dual covered stent technique can successfully treat appropriately selected patients with large or giant ECCA pseudoaneurysms, with the concomitant goals of excluding the pseudoaneurysm and restoring the luminal caliber of the parent artery.

Endovascular clot retrieval for acute ischaemic stroke: the Auckland City Hospital experience.

AIMS: In acute ischaemic stroke, endovascular therapy with the Solitaire FR stent retriever has been shown to double recanalisation rates and the numbers of patients who recover to be functionally independent, when compared to standard therapy. We present the Auckland City Hospital experience of clot retrieval. METHODS: Previously independent ischaemic stroke patients with contraindications to, or no response following, i.v. alteplase, were treated with clot retrieval. All patients had proximal large artery occlusions on CT angiography and many also had CT perfusion scans showing salvageable ischaemic tissue. RESULTS: Clot retrieval was performed in 33 patients (10 women, mean (SD) age of 54 (17) years) since 2011. Twenty-two (67%) patients were first treated with alteplase. Patients fell into three groups: 17 (52%) had anterior circulation occlusion, similar to those in recent clot retrieval studies; 10 (30%) had posterior circulation occlusion; and six (18%) had 'Rescue' clot retrieval, usually with stroke that followed a procedure. Patients with anterior circulation occlusion had a median time from symptom onset to groin puncture of 225 (range 95-450) minutes, full recanalisation occurred in 76%, and by day 90, all 17 were alive and living at home, with 63% functionally independent (modified Rankin Scale (mRS) 0-2). At day 90, eight of 10 posterior circulation occlusion group patients were alive and living at home, four with a mRS of 0-2. In contrast, four of six 'Rescue' patients had died, and another was functionally dependent with a mRS of 4. CONCLUSIONS: Endovascular clot retrieval can be safely and effectively performed in a New Zealand setting with similar results to recent trials in anterior circulation occlusion patients. We suggest that District Health Boards develop clot retrieval services as part of regional hyperacute stroke treatment pathways.

A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA).

BACKGROUND AND HYPOTHESIS: Thrombolysis with tissue plasminogen activator is proven to reduce disability when given within 4·5 h of ischemic stroke onset. However, tissue plasminogen activator only succeeds in recanalizing large vessel arterial occlusion in a minority of patients. We hypothesized that anterior circulation ischemic stroke patients, selected with 'dual target' vessel occlusion and evidence of salvageable brain using computed tomography or magnetic resonance imaging 'mismatch' within 4·5 h of onset, would have improved reperfusion and early neurological improvement when treated with intra-arterial clot retrieval after intravenous tissue plasminogen activator compared with intravenous tissue plasminogen activator alone. STUDY DESIGN: EXTEND-IA is an investigator-initiated, phase II, multicenter prospective, randomized, open-label, blinded-endpoint study. Ischemic stroke patients receiving standard 0·9 mg/kg intravenous tissue plasminogen activator within 4·5 h of stroke onset who have good prestroke functional status (modified Rankin Scale <2, no upper age limit) will undergo multimodal computed tomography or magnetic resonance imaging. Patients who also meet dual target imaging criteria: vessel occlusion (internal carotid or middle cerebral artery) and mismatch (perfusion lesion : ischemic core mismatch ratio >1·2, absolute mismatch >10 ml, ischemic core volume <70 ml) will be randomized to either clot retrieval with the Solitaire FR device after full dose intravenous tissue plasminogen activator, or tissue plasminogen activator alone. STUDY OUTCOMES: The coprimary outcome measure will be reperfusion at 24 h and favorable clinical response (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0-1) at day 3. Secondary outcomes include modified Rankin Scale at day 90, death, and symptomatic intracranial hemorrhage.