Acute In-stent Thrombosis Research Articles

Profile of antiplatelet regimens for emergent carotid stenting in tandem occlusion. Systematic review and meta-analysis

AimTo investigate the optimum antiplatelet therapy regimen (APTR) for emergent carotid artery stenting following mechanical thrombectomy (MT) in stroke patients with tandem occlusion. MethodsA literature search was performed on Pubmed/OVID/Cochran's CENTRAL database for studies from 2015 to 2022. Patient characteristics, antiplatelet regimen type, mTICI, 90 days-mRS, acute in-stent thrombosis (AIST), mortality, intracranial hemorrhage (ICH), and sample size were recorded. Exclusion criteria were non-English literature, sample size < 5 patients, other anticoagulant/antiplatelet therapy, and 100 % stent insertion in one study arm. The studies were assessed using MINORS/GRADE. Meta-analysis and meta-regression with a random effects model were performed. The outcomes were: 90 days-mRS, death, AIST and ICH ResultsFive-hundred-twenty-four studies were retrieved. After applying the exclusion criteria, the final population included 19/534 studies (3.6 %) for 880 patients (46.3 per article). I^2 and Q’s Cochrane were 86.4 % and 132.5 for mRS, 19.9 % and 17.5 for death, 0 % and 9.4 for acute in-stent thrombosis and 62.1 % and 39.7 for intra-cranial haemorrhages, respectively.Patients in the aspirin subgroup had a significantly lower rate of functional independence (mRS≤2) than those in the DAPT subgroup (47 % [CI95 % 42.0 %-52.0 %] vs. 61.9 % [CI95 % 50.8–72.9]; p=0.0007;OR 0.75[CI95 % 0.56–1.01], p=0.06). DAPT significantly decreased the death rate compared with aspirin (8.6 % [CI95 % 5.3 %-11.9 %] vs. 16.7 % [CI95 11.1 %-22.2 %]; p=0.0012). Anti-GPIIb/IIIa demonstrated a trend of increasing the probability of mortality versus DAPT (OR 1.88[CI95 % 0.93–3.86], p=0.08.No significant differences were observed between AIST and ICH in the treatment groups. ConclusionDAPT may increases the chance of obtaining an mRS score ≤2 and reduces mortality.

Acute Sinister in Stent Thrombosis in Endovascular Stenting in SVC Syndrome Secondary to Fibrosing Mediastinitis: Emergent Catheter-Directed Thrombolysis and Outcome—A Case Report

AbstractA 40-year-old woman presented with a 4-week history of headache, facial swelling, and dyspnea. Computed tomography (CT) scan of the chest showed marked narrowing of the superior vena cava (SVC) with surrounding hypodense soft tissue and prominent collateral circulation in mediastinum, and the diagnosis of fibrosing mediastinitis was made. Biopsy suggested active fungal infection and she was treated with oral antifungal therapy. She reported persistent symptoms even after medical management; hence, she was taken for endovascular treatment with placement of a 16 × 60 mm stent (Optimed sinus-XL) in SVC. The patient complained of aggravation in symptoms immediately the next day, and a diagnostic venogram revealed acute total in-stent thrombosis. On an emergency basis, the patient was taken for catheter-directed thrombolysis (CDT) with tissue plasminogen activator (tPA) infusion. She was followed up with CT after1 year, which showed patent stent and no residual or recurrent thrombosis. She is on follow-up with marked relief in symptoms and improved quality of life. Catheter-directed thrombolysis is an emergent treatment modality with limited albeit growing evidence to treat acute in-stent thrombosis. CDT with tPA can be used to effectively treat acute thrombosis with promising results.

Safety and Efficacy of LVIS Jr Stent-assisted Coiling of Intracranial Aneurysms in Small-diameter Parent Arteries : ASingle-center Experience.

To investigate the safety and efficacy of LVIS Jr stent-assisted coiling (SAC) of intracranial aneurysms (IAs) in small-diameter parent arteries and determine the factors influencing incomplete aneurysm occlusion. Clinical and imaging data of 130 patients with IAs in small-diameter parent arteries that were treated with LVIS Jr SAC were retrospectively analyzed. Stent apposition was evaluated by high-resolution flat detector CT, and aneurysm embolization density was evaluated using 2D-DSA. Perioperative complications were recorded. Multivariate logistic regression analyses were performed to determine possible factors for incomplete aneurysm occlusion. In this study, 130 patients (60and 70patients with ruptured and unruptured aneurysms, respectively) were successfully treated with LVIS Jr SAC. Immediate digital subtraction angiography (DSA) showed that the aneurysm occlusion was Raymond-Roy classI, II, IIIa, and IIIb in 93(71.5%), 24(18.5%), 8(6.2%), and 5(3.8%) cases, respectively. There were three cases of acute in-stent thrombosis and two cases of severe vasospasm observed during the perioperative period. The 6‑month follow-up angiograms indicated that complete aneurysm occlusion in 122 patients was 79.5% (97/122). Multivariate logistic regression analyses showed that an aneurysm size > 10.0 mm, parent artery mean diameter < 2.0 mm, and incomplete stent apposition at the aneurysm neck were possible risk factors for incomplete aneurysm occlusion. The LVIS Jr SAC is effective for managing IAs in small-diameter parent arteries. An aneurysm size > 10.0 mm, parent artery mean diameter < 2.0 mm, and incomplete stent apposition at the aneurysm neck are possible risk factors for incomplete aneurysm occlusion.

Three-Year Outcomes, Risk Factors for Restenosis After Stenting for DVT Combined with Iliac Vein Compression Syndrome.

This study aimed to evaluate the safety and efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) and stenting for treating acute iliofemoral deep venous thrombosis (DVT) combined with iliac vein compression syndrome (IVCS), and to identify the predictors of stent restenosis. Patients with acute proximal DVT combined with IVCS underwent PCDT and stenting from January 2017 to December 2022 were enrolled. Primary and secondary patency were assessed by duplex ultrasound (DUS). The morbidity of postthrombotic syndrome (PTS) was assessed by the Villalta score. Risk factors for stent restenosis were assessed using univariate and multivariate Cox regression models. Total of 254 patients were included. The mean follow-up time was 36.06 ± 17.66 months. The primary patency rates at 1 year, 3 years, and 5 years were 92.5%±1.7%, 85.4%±2.4%, and 82.4%±2.9%, respectively. The incidence of stent restenosis was 14.2%. Discontinuation of anticoagulants within one year [hazard ratio (HR) = 5.03; P = .048] was the factor associated with acute in-stent thrombosis. Previous DVT history (HR =2.29; P = .037) and stent placement across the inguinal ligament (HR =6.70; P < .001) were identified as independent risk factors significantly associated with stent restenosis. The overall PTS rate was 19.3%. PCDT with stenting is safe and effective for patients with iliofemoral DVT secondary to IVCS, leading to low rates of PTS. Previous DVT history and stents placed across the inguinal ligament may be predictors of stent restenosis. Furthermore, stent restenosis typically occurs within one year and is mainly caused by acute thrombosis due to discontinuation of anticoagulants.

Willis covered stent treatment for internal carotid artery pseudoaneurysm: A meta-analysis of efficacy and safety

BackgroundPseudoaneurysm (PSA) of internal carotid artery is a rare but severe cerebrovascular disease and difficult to repair surgically. A novel medical device called Willis covered stent (WCS) has been created especially for the treatment of complex cerebrovascular diseases. However, the efficacy and safety of WCS therapy for PSA are still debatable. Additional substantial proof is needed. MethodsTo find research pertaining to WCS treatment for PSA, a systematic review of literature was conducted in the Medline, Embase, Web of Science, CNKI, Wanfang, and CBM databases. The results comprising the data of intraoperative situation, postoperative situation, and follow-up were then included in a meta-analysis. ResultsThe criteria were met by 11 noncomparative studies with 152 patients and 157 PSAs. Technical success rate was nearly 100 % (>0.999 (95 % confidence interval (CI), 0.958, 1.000)), complete occlusion rate was 97.8 % (95 % CI, 0.932, 1.000), and side branch occlusion rate was 0.5 % (95 % CI, 0.001, 0.045). The rates of acute in-stent thrombosis (<0.001 (95 % CI, 0.000, 0.013)) and hemorrhage (<0.001 (95 % CI, 0.000, 0.005)) were both less than 0.1 %. In postoperative situation, surgery-related mortality rate was less than 0.1 % (<0.001 (95 % CI, 0.000, 0.005)). The rates of recurrence (<0.001 (95 % CI, 0.000, 0.002)) and parent artery stenosis (<0.001 (95 % CI, 0.000, 0.008)) were both less than 0.1 %, while late in-stent stenosis occurred in 1.3 % (95 % CI, 0.000, 0.053) of patients. In the end, 98.5 % (95 % CI, 0.943, 1.000) of patients had a good outcome. ConclusionThe application of WCS could be effective and safe for PSAs. The findings of this study could serve as a reference for upcoming clinical trials.

Shockwave intravascular lithotripsy as a novel strategy for balloon undilatable heavily calcified chronic total occlusion lesions.

The successful percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) improves the long-term outcome in patients with coronary artery disease (CAD). Heavy calcification remains one of the strongest predictors of an unfavorable outcome of PCI. In this case series study, shockwave intravascular lithotripsy (S-IVL)-a novel balloon-based coronary system facilitating modification of calcified coronary lesions was evaluated. The study population consisted of five heavily calcified, undilatable-CTOs lesions treated with S-IVL selected out of all consecutive CTO-PCI patients performed at two high-volume cardiac centers. The registry included 5 patients successful CTO - S-IVL procedures with an average J-CTO of 2.6 points. In the short-term follow-up period, including the first 30 days, no cases of acute in-stent thrombosis, target lesion failure, or major adverse cardiac and cerebrovascular events were noted. The present data suggest that this approach can be safe and useful in the treatment of complex calcified CTO lesions.

Rescue treatment with tPA for refractory thromboembolism during stent-assisted coiling of a ruptured intracranial aneurysm: A case report

Thromboembolic complications during stent-assisted coiling of ruptured intracranial aneurysms are major complications that can cause serious neurological deficits. Management strategies include medical thrombolysis, mechanical thrombectomy with suction aspiration or stent retrieval, and rescue stenting. The existing literature suggests that tissue plasminogen activator agents should be used cautiously because of the high risk of severe bleeding at the aneurysm. We present the case of a ruptured anterior communicating artery aneurysm. Acute in-stent thrombosis occurred during the stent-assisted coiling of the aneurysm. Rescue therapy with tirofiban, suction aspiration, and rescue stenting was attempted; however, these methods failed. Finally, tissue plasminogen activator infusion was performed, which successfully dissolved the thrombus and restored blood flow. Follow-up brain computed tomography revealed no increase in hemorrhage volume.

Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data

BackgroundThe periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis....

Endovascular treatment of unruptured cavernous carotid aneurysms using flow diverter devices in Vietnam: A single-center prospective study

ObjectiveThis prospective study aims to investigate the safety and effectiveness of flow diverter (FD) in the treatment of unruptured cavernous carotid aneurysms (CCAs) in Vietnam. MethodsA single-center, prospective case series of 32 patients with unruptured CCAs treated by FD at our center from January 2017 to January 2022 was performed. We analyzed the aneurysm characteristics, procedure details, aneurysm occlusion rate, evolution of clinical symptoms, complications, and functional outcomes after treatment. Angiographic study was scheduled at the 6-month and 12-month follow-up. The occlusion rate was evaluated according to the O’Kelly-Marotta (OKM) Scale. Results35 FDs were deployed to treat 32 unruptured CCAs in 32 patients (mean age, 59.25; mean aneurysm size, 12.13 mm). Stent implantation was successful in all patients. Single FD was used in 29 cases (90.6%). Adjunctive coils were placed in five patients (15.6%). Complete aneurysm occlusion was achieved in 61.3% at 6 months and 96.4% at 12 months. Favorable outcome defined as mRS 0–2 was reported in all except one patient. Complete resolution or significant improvement of clinical symptoms was noted in 29 of 30 symptomatic patients (96.7%). Periprocedural complications included vessel perforation with severe SAH leading to death in one case (3.1%), minor vasospasm in four (12.5%), acute in-stent thrombosis in two (6.3%), and puncture-related hematoma in two (6.3%). All of these patients were successfully managed without clinical sequalae after the procedure except for one case. ConclusionFD represents a safe and effective treatment modality that might be considered as a valuable alternative to standard endovascular coiling techniques or carotid sacrifice for unruptured CCAs.

Safety and efficacy of the expressman extension system for complex coronary lesions during percutaneous coronary intervention.

Safety and efficacy of the expressman extension system for complex coronary lesions during percutaneous coronary intervention.

Comparison of post-procedural rise of cardiac biomarkers after implantation of an everolimus-eluting bioresorbable vascular scaffold versus everolimus-eluting metallic stent in patients with long/diffuse LAD disease

Objectives This study sought to evaluate the incidence and the mechanism of post-procedural cardiac biomarker (CB) rise following device implantation. Background A fully bioresorbable Absorb scaffold, compared with everolimus-eluting metallic stents (EES), might be associated with a higher incidence of periprocedural myocardial injury. Methods Prospective nonrandomized comparative study enrolled 52 patients with stable myocardial ischemia with diffuse/ long LAD lesion for either an everolimus-eluting bioresorbable vascular (BVS) scaffold (22 patients) or an EES (30 patients), 3 types of CB (creatine kinase (CK), creatine kinase-myocardial band (CK-MB), and troponin) were obtained before and after procedure. Per protocol, periprocedural myocardial infarction (PMI) was defined as CK rise &gt;2 the upper limit of normal with CK-MB rise. Results Incidence of side branch occlusion (SBO) and any anatomic complications assessed by angiography was similar between the 2 treatment arms (SBO: Absorb: 4.5% vs. Xience: 6.7%, p=1; One PMI with acute instent thrombosis occurred in EES group. Dissection occurred in only 1 patient in BVS arm after stent implantation; this event was not associated with elevated cardiac biomarkers. One patient had PMI in BVS arm with no angiographic complications to explain it.

Feasibility and Results of the Stentectomy Procedure Performed as Rescue Treatment for Acute Thrombosis of Self-Expandable Intracranial Stents: A Case Series.

Self-expandable stents have been increasingly used for endovascular treatment of intracranial aneurysms. Because the usage of intracranial stents has increased overall, total numbers of complications associated with these devices have increased. Thrombosis, distortion, or incomplete opening of stents are potential complications that may result in occlusion of the parent artery. In such cases, removal of the stent (stentectomy) may be the only solution to avoid serious clinical consequences. To investigate the feasibility and efficacy of a novel stentectomy technique for removal of thrombosed self-expandable stents. A retrospective review was performed of patients who underwent the stentectomy procedure. Initial and follow-up imaging and clinical outcomes were assessed. Immediate postprocedural and follow-up clinical statuses were assessed using the modified Rankin scale. Seven patients were included in this study (mean age: 54.1 years). The stentectomy was successful in 6 of 7 patients (85.7%). Seven stents in 6 patients were successfully removed to treat the acute in-stent thrombosis that was resistant to alternative bail-out treatments. The removed stents were self-expandable braided in 2 patients, flow diverters in 2 patients, and laser cut open-cell stents in 2 patients. Stentectomy failed to retrieve a thrombosed braided stent in 1 patient. The modified Rankin scale score of all patients who underwent a success stentectomy was ≤1. The stentectomy procedure using the defined technique is feasible to retrieve thrombosed stents and effective to restore the blood flow. It can be considered a last resort option to treat acute in-stent thrombosis resistant to alternative bail-out treatments.

736 Hazy spots: through the eye of optical coherence tomography

Abstract Aims Acute stent thrombosis after coronary artery stent placement is a rare but serious complication in percutaneous coronary intervention (PCI). Stenting culprit lesions in acute coronary syndrome (ACS) has higher risk of acute stent thrombosis than stable coronary artery disease, and many local and systemic factors may contribute to increase this risk. Tissue protrusion (TP), and in particular, plaque prolapse after PCI can play a role in acute stent thrombosis, and intra-vessel imaging is the principal instrument to identify such underlying lumen alteration after stent implantation, and guide intervention. Methods and results We report the case of a 54-year-old man with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, obesity and no other relevant comorbidities in remote history, who underwent a coronary angiography for an unstable angina. A long, calcific sub-occlusion of the left anterior descending artery (LAD), which involved LAD-first diagonal branch (D1) bifurcation (Medina 1.1.1) and LAD-D2 bifurcation (Medina 1.1.0) was found. After deployment of two overlapping drug-eluting stents (DES), (ULTIMASTER TANSEI 3.0 × 38 mm and 3.0 × 21 mm) and struts apposition optimization with sequence of proximal optimization technique (POT) on D1 and D2, and a kissing balloon technique (KS) on LAD-D2 bifurcation, a ‘hazy’ in-stent image was detected right after the LAD-D2 bifurcation, suggesting an acute in-stent thrombosis, in absence of flow alteration (TIMI 3), symptoms or ECG modifications. Multiple thrombus-aspiration were made and resulted in abundant thrombus removal and improvement in the angiographic image, with persistent valid flow on every three vessels (TIMI 3). After 5 days of triple anticoagulant therapy with ticagrelor, cardioaspirin and UFH infusion, he underwent a new coronary angiography control. A similar ‘hazy’ image was detected right after LAD-D2 bifurcation within the LAD. An optical coherence tomography (OCT) pullback was made to assess the nature of the angiographic finding. OCT showed good struts apposition in almost every cross-sectional images, but an evident TP was detected right on the angiographic hazy spot. OCT allowed to evaluate the lipid-richness of the stented plaque and the nature of the TP, which was mixed with evident both white and red thrombus apposition (minimum luminal area measured 4.5 mm2). OCT guided a new PCI, with a stent-in-stent implantation on LAD. TP was absent on the post-PCI OCT run. Conclusions In this report, we showed the usefulness of OCT in revealing a potential high risk thrombogenic source. OCT not only characterized something that angiography alone couldn’t, but suggested the etiology of the amount of thrombus removed by the vessel during the first PCI. Indeed, despite an optimized cycle of anticoagulant therapy, OCT still revealed several mixed thrombus apposition on the TP, and this suggested its role in the acute stent thrombosis. OCT guided the choice to appose a new stent-in-stent to solve a potential thrombogenic source.

Twelve months results from a prospective real-world multicenter clinical practice of CAS using the CGuard Embolic Prevention System (EPS): the IRONGUARD 2 study

Abstract Objectives When compared to carotid endarterectomy, carotid artery stenting (CAS) has been associated to a higher rate of post procedural neurologic events, potentially related to plaque's debris prolapsing through stent's mesh. Consequently, the need for increased plaque coverage has resulted in the development of dual layered mesh covered carotid stent systems (DLS). However, recent reports demonstrated that these devices are also associated with a not-negligible restenosis rate among the studies. Aim of this registry was to evaluate 1-year safety and efficacy of DLS for CAS in the clinical practice. Methods From January 2017 to June 2019 a physician-initiated, prospective, multispecialty, registry enrolled 733 consecutive patients undergoing CAS using the CGuard Embolic Prevention System (EPS) in 20 centres. The primary endpoint was the occurrence of death and stroke at 1 year; secondary endpoints were transient ischemic attack (TIA), acute myocardial infarction (AMI), restenosis rate and in-stent thrombosis, ECA occlusion at 1 year. Results Among all enrolled subjects, late results were collected for 726 patients (99.04%). Dual antiplatelet therapy was maintained for at least 30 days post-procedurally in all patients, and for 3 months in 295 (40.63%), according with each center routine practice. After 30th post-operative day, new neurological adverse event was detected in 5 patients (0.68%), accounting for 1 minor stroke (0.13%), and 4 (0.55%) transient ischemic attacks. Eight patients (1.10%) died during the study period: 2 fatal acute myocardial infarctions (0.27%), 4 malignancies (0.55%), 1 suicide (0.13%), 1 undefined complication in Guillain-Barré Syndrome (0.13%). At duplex ultrasound examination, internal carotid artery was found patent in all but two patients (0.27%), and 2 asymptomatic in-stent restenosis (0.27%) were judged to be severe (&amp;gt;70%, peak systolic velocity &amp;gt;450cm/sec) and successfully treated by stent-in-stent. External carotid artery patency rate was 98.8% (718/726). At univariate analysis, post-dilatation (p=0.62; OR: 0.67; CI95%: 0.13–3.34), and dual antiplatelet therapy duration (p=0.97; OR: 0.96; CI95%: 0.11–8.31) were found to be not statistically related to occlusion and/or restenosis occurrence. Conclusion This real-world registry suggests that use of EPS in clinical practice is safe and associated to a minimal occurrence of adverse neurological events up to 12 months follow up. Funding Acknowledgement Type of funding sources: None.

Application of covered stent graft in the treatment of complex carotid artery lesions: A single center experience.

To assess the clinical efficiency and imaging outcome of applying covered stent grafts for the treatment of complex carotid artery lesions. A total of 39 consecutive patients with carotid artery lesions treated with covered stent grafts at our institution from December 2016 to December 2019 were reviewed. Two kinds of stent including self-expandable covered stent (Viabahn; W. L. Gore & Associates) and balloon-expandable covered stent (Willis; Microport) were applied. The angiograms immediately after the procedure, perioperative complications, and follow-up outcomes were recorded. Based on imaging features, 11 patients exhibited pseudoaneurysms, 23 patients had blood blister-like aneurysms (BBAs), and five patients were carotid cavernous fistulas. A total of 40 stent implantations were performed, including nine Viabahn stents and 31 Willis stents. Two patients received double implants of Willis stents. Stent failed to perform for one patient due to tortuous parent artery. The angiography reports immediately after the procedure showed that the lesions in 36 patients were completely occluded, whereas two patients had minimal endoleaks. With respect to the occurrence of procedural complications, an aneurysm ruptured during the procedure in one case, which resulted in CCF, and acute in-stent thrombosis occurred in another case. Clinical and angiographic follow-up (11.2±2.4 months) sessions were conducted for 38 patients and a complete lesion exclusion was achieved in 36 patients. The minimal endoleak persisted in one patient and another patient experienced recurrence with stent migration, leading to ipsilateral blepharoptosis. However, none of the patients developed hemorrhage or ischemia and in-stent stenosis was not observed. Covered stent grafts appear to be a safe and feasible for the treatment of complex carotid artery lesions. Despite the potential for stent delivery failure as well as endoleak and procedure-related complications, covered stent grafts should be considered when selecting the optimal treatment strategy.

Management of tandem occlusions in patients who receive rtPA.

Tandem occlusions exist in 17-32% of large vessel occlusion (LVO) strokes. A significant concern is bleeding when carotid stenting is performed in tandem with thrombectomy due the administration of antiplatelet agents such as glycoprotein IIb/IIIa inhibitors (GP2b3aI) after receiving rtPA, but data are limited in this setting. A mutlicenter, retrospective chart review was conducted at two comprehensive stroke centers to assess the safety and efficacy of using GP2b3aI to facilitate carotid stent placement simultaneously with endovascular thrombectomy in patients who have received rtPA. Overall, 32 patients were included in this study, with average age of 66.3 ± 10.4years and predominantly male (87.5%). The cause of stroke was mostly large artery atherosclerosis (59.4%) and the thrombectomy target vessels were typically first- or second segment middle cerebral artery (37.5% and 31.3%). Time from symptom onset to rtPA bolus was 1.8h [interquartile range (IQR) 1.5-2.7], rtPA bolus to first pass was 2h [IQR 1.5-3.1], rtPA bolus to GP2b3aI bolus was 2h [IQR 1.6-3.5], and rtPA bolus to aspirin and clopidogrel administration was 4.3h [IQR 2.6-8.9] and 6.6h [IQR 4.5-11.6] respectively. No patients had acute in-stent thrombosis or post-op bleeding from the access site. Two patients (6.3%) had significant hemorrhagic conversion. The use of GP2b3aI in the setting of tandem occlusions that required emergent stent placement post-rtPA appears safe and effective. Given the small sample size, these findings should be interpreted cautiously, and need to be confirmed in a larger patient population.

Flow modification on the internal carotid artery bifurcation region and A1 segment after M1-internal carotid artery flow diverter deployment

BackgroundClinical and hemodynamic consequences of flow diverters extending from the M1 to the internal carotid artery (ICA), covering the A1 segment, have rarely been investigated. We aimed to provide angiographic...

Endovascular Treatment of Complex Vascular Diseases of the Internal Carotid Artery Using the Willis Covered Stent: Preliminary Experience and Technical Considerations.

Purpose: The Willis covered stent (WCS) is used to treat complex vascular diseases of the internal carotid artery; however, its performance requires further investigation. This study aimed to present our single-center clinical results and experience of endovascular repair of complex vascular diseases of the internal carotid artery using the WCS.Methods: Patients who presented with complex vascular diseases of the internal carotid artery and who were treated with the WCS from December 2013 to September 2018 were retrospectively reviewed. Procedural results, perioperative complications, incidence of endoleak, and follow-up outcomes were analyzed.Results: Sixty-five patients were enrolled. A total of 25 large aneurysms, 10 pseudoaneurysms, 14 blood blister-like aneurysms, 11 carotid–cavernous fistulas, and 5 surgical injuries were assessed. WCS placement was successful in all patients. Immediate angiography showed that complete repair of the target artery was achieved in 56 patients (86.2%). Endoleak was observed in nine patients, including seven type I endoleaks and two type II endoleaks. Occlusion of a side-branch vessel occurred in four patients. Acute in-stent thrombosis occurred in one patient. No ischemic or hemorrhagic events or other complications developed during the perioperative and follow-up periods. Angiographic follow-up (mean duration, 12 ± 3.29 months) was performed in 60 patients and showed complete target artery repair in 58 patients, and asymptomatic mild to moderate in-stent stenosis was observed in four patients. Slight endoleak persisted in two patients without enlargement or rupture of the residual lumen.Conclusion: WCS implantation is safe, feasible, and efficacious for endovascular repair in patients with complex vascular diseases of the internal carotid artery, showing excellent short-term target artery patency and clinical outcomes.

Dual-roadmap guidance for endovascular recanalization of medically refractory non-acute intracranial arterial occlusions: consecutive multicenter series and technical review

BackgroundThe optimal treatment for medically refractory non-acute intracranial artery occlusion is uncertain, and endovascular recanalization remains a technical challenge. Here, a multicenter clinical experience of dual-roadmap guidance for endovascular recanalization...

Mechanical Thrombectomy of Acutely Occluded Flow-Diverters - Neuroendovascular Surgical Technique Demonstration: 2-Dimensional Operative Video.

Flow-diversion with pipeline embolization devices (PED, Medtronic, Dublin, Ireland) is widely used for embolization of complex intracranial aneurysms.1 In-stent thrombosis can be a dreadful complication after PED deployment. Intra-arterial glycoprotein IIb-IIIa inhibitors and intravenous tissue plasminogen activator have been used in an attempt to achieve recanalization.2 However, large clots may not be effectively dissolved by pharmacological agents, thus requiring mechanical thrombectomy (MT).3 Our group recently published the first technical report on successful MT of acutely occluded PEDs in 2 patients.4 Here, we showcase the successful MT of a patient who sustained acute in-stent PED thrombosis. Informed written consent was obtained. In this case, we combined stentriever and contact aspiration thrombectomy techniques. We highlight important pitfalls and tips to prevent PED displacement, removal or vessel injury during endovascular manipulation. The most important consideration is to deploy the distal end of the stentriever inside the PED but also as distally as possible. Thus, correct apposition and alignment of the distal markers of both devices is performed under "native" unsubstracted fluoroscopic view (for better PED visualization) before MT. In this surgical video we describe the technique in detail.