Factors Determining Periprocedural and Long-term Complications of High Risk Carotid Artery Stenting.

BACKGROUND AND PURPOSE: Carotid artery stenting (CAS) has been, historically, an alternative to open endarterectomy (CEA) for stroke prevention in high risk patients with carotid atherosclerosis. We sought to determine the rates of periprocedural and long-term stroke or death and the risk factors for complications after CAS in our high risk patient population. METHODS: Clinical and treatment variables of consecutive CAS procedures performed between 2002 and 2011 were analyzed. Using univariate and multivariate logistic regression analyses we examined how patient characteristics influenced outcomes and changes in modified Rankin Score (mRS). RESULTS: In 152 patients, the composite total of periprocedural death, stroke, transient ischemic attack (TIA) and myocardial infarction (MI) rate was 3.95% (6/152). Chronic kidney disease (CKD) was strongly associated with periprocedural complications (p<0.001). Coronary artery disease/peripheral vascular disease (CAD/PVD) (p=0.03), dyslipidemia (p=0.02), CKD (p=0.01), and contralateral internal carotid artery stenosis (p=0.02) were non-modifiable risk factors for mRS increase. There were 25 deaths, 8 strokes, 11 TIAs, and 1 MI (mean follow-up 38.4 months, range 0-116 months). The presence of CAD/PVD (p=0.009) and dyslipidemia (p=0.002) were significantly associated with long-term complications. CONCLUSION: CAS was performed with low periprocedural complications in high-risk patients. Our rates compare very favorably to large-scale trials that have ideal patients. This data encourages the consideration of CAS in patients considered high risk for CEA and provides possible patient characteristics (CKD) to help with periprocedural risk stratification.

Direct Puncture of the Superficial Temporal Artery in Embolization of a Scalp Arteriovenous Fistula: A Case Report.

We describe a minimally invasive endovascular approach to treat an arteriovenous fistula of the scalp. We performed a direct puncture of the lesion through the patient's scalp for liquid embolic agent injection along with external compression of the superficial temporal artery to perform a "manual pressure-cooker technique." The combination of these minimally invasive techniques resulted in an excellent clinical and radiographic outcome.

Clinical and angiographic outcomes of stent-assisted coiling of intracranial aneurysms.

BACKGROUND: Despite the increasing use of stent-assisted coiling (SAC), data on its long-term clinical and angiographic results are limited. OBJECTIVE: The objective of this article is to assess the long-term clinical and angiographic outcomes in SAC in our single-center practice. METHODS: We conducted a retrospective analysis of intracranial aneurysms treated with detachable coils during the period 2003-2012. Patients were divided into SAC and non-SAC groups and were analyzed for aneurysm occlusion, major recurrence and clinical outcome. Logistic regression analyses identified factors associated with clinical/angiographic outcomes (p value <0.05 was statistically significant). RESULTS: A total of 516 procedures met inclusion criteria: Sixty-three (12.2%) patients underwent SAC, of whom 56 (89%) had an elective procedure whereas 286 (63.1%) aneurysms from the non-SAC group were ruptured. In the unruptured subcohort, baseline class I was achieved in 24 (38%, p = 0.91), and predischarge modified Rankin scale score (mRS) 0-2 was obtained in 96.4% of cases in the SAC group versus 90.4% in the non-stent group. The major recurrence was 9.5% versus 11.3% in the SAC and non-SAC group, respectively (p = 0.003). At last clinical assessment, 98.2% of the patients from the unruptured SAC group had mRS 0-2 (mean follow-up, 58 months) versus 93.6% (mean follow-up, 56 months) in the unruptured non-SAC group (p = 0.64). Periprocedural vasospasm was associated with long-term poor outcome in the unruptured SAC subcohort (p = 0.0008). CONCLUSIONS: SAC and non-SCA techniques show comparable safety and clinical outcome. The SAC technique significantly decreases retreatment rates. Periprocedural vasospasm resulting from vessel manipulation is associated with poor outcome in SAC of unruptured aneurysms.

A matched-pair cluster design study protocol to evaluate implementation of the Canadian C-spine rule in hospital emergency departments: Phase III.

BACKGROUND: Physicians in Canadian emergency departments (EDs) annually treat 185,000 alert and stable trauma victims who are at risk for cervical spine (C-spine) injury. However, only 0.9% of these patients have suffered a cervical spine fracture. Current use of radiography is not efficient. The Canadian C-Spine Rule is designed to allow physicians to be more selective and accurate in ordering C-spine radiography, and to rapidly clear the C-spine without the need for radiography in many patients. The goal of this phase III study is to evaluate the effectiveness of an active strategy to implement the Canadian C-Spine Rule into physician practice. Specific objectives are to: 1) determine clinical impact, 2) determine sustainability, 3) evaluate performance, and 4) conduct an economic evaluation. METHODS: We propose a matched-pair cluster design study that compares outcomes during three consecutive 12-months "before," "after," and "decay" periods at six pairs of "intervention" and "control" sites. These 12 hospital ED sites will be stratified as "teaching" or "community" hospitals, matched according to baseline C-spine radiography ordering rates, and then allocated within each pair to either intervention or control groups. During the "after" period at the intervention sites, simple and inexpensive strategies will be employed to actively implement the Canadian C-Spine Rule. The following outcomes will be assessed: 1) measures of clinical impact, 2) performance of the Canadian C-Spine Rule, and 3) economic measures. During the 12-month "decay" period, implementation strategies will continue, allowing us to evaluate the sustainability of the effect. We estimate a sample size of 4,800 patients in each period in order to have adequate power to evaluate the main outcomes. DISCUSSION: Phase I successfully derived the Canadian C-Spine Rule and phase II confirmed the accuracy and safety of the rule, hence, the potential for physicians to improve care. What remains unknown is the actual change in clinical behaviors that can be affected by implementation of the Canadian C-Spine Rule, and whether implementation can be achieved with simple and inexpensive measures. We believe that the Canadian C-Spine Rule has the potential to significantly reduce health care costs and improve the efficiency of patient flow in busy Canadian EDs.