Follow-up Angiographic Studies Research Articles

Stent-Associated Flow Remodeling Causes Further Occlusion of Incompletely Coiled Aneurysms

Incomplete coil occlusion is associated with increased risk of aneurysm recurrence. We hypothesize that intracranial stents can cause flow remodeling, which promotes further occlusion of an incompletely coiled aneurysm. To study our hypothesis by comparing the follow-up angiographic outcomes of stented and nonstented incompletely coiled aneurysms. From January 2006 through December 2009, the senior author performed 324 initial coilings of previously untreated aneurysms, 145 of which were Raymond classification 2 and 3. Follow-up angiographic studies were available for 109 of these aneurysms (75%). Angiographic outcomes for stented vs nonstented incompletely coiled aneurysms were compared. A multivariate analysis was performed to identify factors related to the progression of occlusion at follow-up, with adjustment for aneurysm location, size, neck size, Hunt-Hess grade, stent use, initial Raymond score, packing density, age, sex, and medical comorbidities. Of the 109 aneurysms, 37 were stented and 72 were not stented. With a median follow-up time of 15.4 months, 33 stented aneurysms (89%) progressed to complete occlusion compared with 29 nonstented aneurysms (40%). Recanalization rates were lower in the stented group (8.1%) compared with the nonstented group (37.5%; P < .001). On multivariate analysis, stent use (odds ratio, 18.5; 95% confidence interval, 4.3-76.9) and packing density (odds ratio, 1.093; 95% confidence interval, 1.021-1.170) were significant predictors of the progression of occlusion. Aneurysm size was negatively correlated with the progression of occlusion (odds ratio, 0.844; 95% confidence interval, 0.724-0.983). Stent-assisted coiling causes progression of occlusion, possibly by a flow remodeling effect. The odds of progression of occlusion of stent-coiled aneurysms were 18.5 times that of nonstented aneurysms.

Long-term angiographic outcomes of post-Sirolimus-eluting stent restenosis in Japanese patients

Though restenosis after drug-eluting stent implantation is still observed, the factors affecting post-sirolimus-eluting stent restenosis (re-restenosis) have not been fully determined. We evaluated the long-term angiographic outcomes and examined background factors affecting re-restenosis. We enrolled 51 patients with 68 sirolimus-eluting stent (SES) restenosis lesions who underwent target lesion revascularization (TLR) and angiographic follow-up studies. Re-restenosis was observed in 29 of 68 restenosis lesions, and the rate was 42.6%. Study subjects were divided into two groups: a re-restenosis (Re-R) group (20 patients) with 29 lesions and a restenosis (R) group (31 patients) with 39 lesions with no re-restenosis. There were no differences in age, sex, coronary risk factors, past history, or medications between the two groups. Re-restenosis was observed more frequently in the right coronary artery (Re-R group vs. R group; 65.5 vs. 33.3%, P = 0.009). The incidence of stent fracture was higher in the Re-R group (Re-R group vs. R group; 48.3 vs. 12.8%, P = 0.003). QCA results showed that the initial lesion length at the time of first coronary intervention was significantly longer in the Re-R group (Re-R group vs. R group; 21.6 ± 3.37 vs. 12.6 ± 4.98 mm, P = 0.049). The rate of re-restenosis was 47.1% when treated with POBA alone, while it was 36.7% with SES treatment. In multivariate analysis, the initial lesion length at the time of first coronary intervention (odds ratio = 1.64, 95% CI 1.29-2.06, P < 0.001) and stent fracture (odds ratio = 12.42, 95% CI 1.89-81.4, P = 0.009) were independent predictors of re-restenosis. This study demonstrates that recurrent restenosis with SES treatment is associated with lesion length and stent fracture, a finding that is beneficial in the management of restenosis after SES implantation.

Sixteen-year single-surgeon experience with coil embolization for ruptured intracranial aneurysms: recurrence rates and incidence of late rebleeding

Over a 16-year period, 570 patients presenting with acute aneurysmal subarachnoid hemorrhage were successfully treated using endosaccular coil embolization within 30 days of hemorrhage by a single surgeon. Patients were followed to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting against rebleeding. Patients were followed for 6 to 191 months (mean 73.7 months, median 67 months) by clinical review, angiography performed at 6 and 24 months posttreatment, and questionnaires sent via the postal service every 5 years. Late rebleeding was defined as > 30 days after treatment. Stable angiographic occlusion was evident in 74.5% of small, 72.2% of large, and 60% of giant aneurysms. Recurrent filling was found in 119 (26.3%) of 452 aneurysms. Rebleeding was diagnosed in 9 patients (6 treated aneurysms) and occurred between 2 and 114 months posttreatment. It was due to aneurysm recurrence in 6 patients, rupture of a coincidental untreated aneurysm in 2 patients, and rupture of a de novo aneurysm in 1 patient. Rebleeding occurred in 3 (2.5%) of 119 unstable aneurysms and in 3 (0.9%) of 333 stable aneurysms, as seen on initial follow-up angiography studies. Annual rebleeding rates ranged from 0.2% to 0.6% for all causes and from 0.2% to 0.4% for rebleeding of treated aneurysms. No rebleeding was recorded after the first decade, with 138 patients having more than 10 years of follow-up. Periodic follow-up with angiographic studies after coil embolization is recommended to identify aneurysm recurrence and patients at a high risk of late rebleeding in the medium term. More frequent follow-up is recommended for patients harboring coincidental unruptured aneurysms.

E-016 Enterprise stent assisted coil embolization of cerebral aneurysms

IntroductionCerebral aneurysms have morphometric features that influence the initial and long term success of coil embolization. Advances in coil assist technology now permit endovascular treatment of previously uncoilable aneurysms. We...

Prevention of secondary ischemic events by superficial temporal artery–middle cerebral artery bypass surgery after tuberculosis-induced vasculopathy in a 5-year-old child

Tuberculosis-related vasculopathy and resulting ischemic events are a common finding after tuberculous meningitis (TBM) in children. The authors report on a case of recurring ischemic episodes that were refractory to repetitive endovascular procedures (transluminal angioplasty, stent insertion, in-stent vessel dilation). After failure of endovascular treatment, extracranial-intracranial (EC-IC) bypass surgery was performed to prevent further ischemia. This 5-year-old girl presented with a series of ischemic events in the left middle cerebral artery (MCA) territory 12 months after her presentation with TBM. Angiography studies showed a 50% lumen reduction of the left MCA. After failure of antithrombocyte aggregation and repeated endovascular procedures to prevent new ischemia, EC-IC bypass surgery was performed. The left superficial temporal artery-MCA bypass was found to be capable of preventing new ischemic events in the 21-month follow-up period, despite a near-total MCA occlusion on follow-up conventional and MR angiography studies. Bypass surgery seems to be a reliable tool to augment cerebral blood flow in tuberculosis-related stenoocclusive changes of cerebral vasculature after the failure of endovascular procedures.

Stent-assisted coil embolization followed by a stent-within-a-stent technique for ruptured dissecting aneurysms of the intracranial vertebrobasilar artery

A ruptured dissecting aneurysm of the vertebrobasilar artery (VBA-DA) is a well-known cause of acute subarachnoid hemorrhage (SAH) with a high rate of early rebleeding. Internal trapping of the parent artery, including the dissected segment, is one of the most reliable techniques to prevent rebleeding. However, for a ruptured VBA-DA not suitable for internal trapping, the optimal treatment method has not been well established. The authors describe their experience in treating ruptured VBA-DAs not amenable to internal trapping of the parent artery with stent-assisted coil embolization (SAC) followed by a stent-within-a-stent (SWS) technique. Eleven patients-6 men and 5 women with a mean age of 48 years and each with a ruptured VBA-DA not amenable to internal trapping of the parent artery-underwent an SAC-SWS between November 2005 and October 2007. The feasibility and clinical and angiographic outcomes of this combined procedure were retrospectively evaluated. The SAC-SWS was successful without any treatment-related complications in all 11 patients. Immediate posttreatment angiograms revealed complete obliteration of the DA sac in 3 patients, near-complete obliteration in 7, and partial obliteration in 1. One patient died as a direct consequence of the initial SAH. All 10 surviving patients had excellent clinical outcomes (Glasgow Outcome Scale Score 5) without posttreatment rebleeding during a follow-up period of 8-24 months (mean follow-up 15 months). Angiographic follow-up at 6-12 months after treatment was possible at least once in all surviving patients. Nine VBA-DAs showed complete obliteration; the other aneurysm, which had appeared partially obliterated immediately after treatment, demonstrated progressive obliteration on 2 consecutive follow-up angiography studies. There was no in-stent stenosis or occlusion of the branch or perforating vessels. The SAC-SWS technique seems to be a feasible and effective reconstructive treatment option for a ruptured VBA-DA. The technique may be considered as an alternative therapeutic option in selected patients with ruptured VBA-DAs unsuitable for internal trapping of the parent artery.

Causes of non-functioning right internal mammary used in a Y-graft configuration: insight from a 6-month systematic angiographic trial☆☆☆

Y-graft configuration with left and right ITA (RITA) allows complete arterial revascularisation. We previously compared two types of ITA revascularisation in a prospective randomised trial with a systematic 6-month angiographic follow-up study. The present study is a secondary analysis of these populations to evaluate the angiographic parameters influencing the function of the RITA used in a Y-graft configuration. The functionality of the RITA was based on the TIMI grade flow: in TIMI grade 0 (occluded graft) and in TIMI grade 1 or 2 (balanced flow), the RITA was considered not functional. RITA was considered functional when a complete opacification (TIMI 3) of all anastomoses of the targeted coronary vessels was observed. A total of 25.3% of RITA were not functional. In univariate analysis, the number of anastomoses, the type and size of grafted coronary segments and the severity of the native coronary stenosis influenced ITA function. In multivariate analysis, the function of the RITA was positively influenced by the number of anastomoses (OR=0.5, 95% CI: 0.4-0.7), and a severely narrowed first circumflex (OR=39.1, CI: 8.1-189.2) and negatively by the presence of a grafted intermediate coronary artery (OR=0.01, CI: 0.003-0.06), and of a grafted RCA (OR=0.08, CI: 0.02-0.35). The size of targeted vessel, history of infarction and regional myocardial function did not influence ITA function. In this systematic angiographic study, the function of the RITA used as a Y-graft was significantly improved when used on several branches of the circumflex artery or on a severely narrowed first circumflex. Grafting of the intermediate branch or of a RCA has a negative prognostic influence on graft function.

Durability of Antirestenotic Efficacy in Drug-Eluting Stents With and Without Permanent Polymer

We sought to assess changes in antirestenotic efficacy of drug-eluting stents (DES) by restudying subjects at 2 time points after coronary stenting (6 to 8 months and 2 years) and to compare differences in time courses of late luminal loss (LLL) between 3 different DES platforms in use at our institution. DES therapy is associated with low levels of LLL at 6 to 8 months. The temporal course of neointimal formation after this time point remains unclear. This prospective, observational, systematic angiographic follow-up study was conducted at 2 centers in Munich, Germany. Patients underwent stenting with permanent-polymer rapamycin-eluting stents (RES), polymer-free RES, or permanent-polymer paclitaxel-eluting stents (PES). The primary end point was delayed LLL (the difference in in-stent LLL between 6 to 8 months and 2 years). Of 2,588 patients undergoing stenting, 2,030 patients (78.4%) had 6- to 8-month angiographic follow-up and were enrolled in the study. Target lesion revascularization was performed in 259 patients; these patients were not considered for further angiographic analysis. Of 1,771 remaining patients, 1,331 had available 2-year reangiographic data (75.2%). Overall mean (SD) delayed LLL was 0.12 +/- 0.49 mm (0.17 +/- 0.50 mm, 0.01 +/- 0.42 mm, and 0.13 +/- 0.50 mm in permanent-polymer RES, polymer-free RES, and permanent-polymer PES groups, respectively [p < 0.001]). In multivariate analysis, only stent type (in favor of polymer-free RES) predicted delayed LLL. Ongoing erosion of luminal caliber beyond 6 to 8 months after the index procedure is observed following DES implantation. Absence of permanent polymer from the DES platform seems to militate against this effect.

Successful treatment of a blood blister-like aneurysm of the internal carotid artery by trapping with a high-flow bypass

Treatment of blood blister-like aneurysms of the internal carotid artery (ICA) is difficult because the wall of the aneurysm is fragile and there is a high risk of rebleeding. There has been no consensus on the best way to treat these aneurysms. A 32-year-old woman presented with subarachnoid hemorrhage (SAH) caused by a ruptured blood blister-like aneurysm of the ICA. The site of the aneursym was clipped. Although angiography 1 week after the operation showed that the aneurysm had been treated successfully, 3 weeks after the initial operation, the aneurysm was found to have recurred to the distal side. In a second operation, the aneurysm was successfully treated by trapping with a high-flow bypass. This case shows that clipping of the rupture site can be insufficient to treat blood blister-like aneurysm of the ICA causing SAH, even if the aneurysm seems to have resolved in follow-up angiographic studies. Trapping of the ICA with a bypass, if necessary a high-flow bypass, is recommended.

Conservative Medication Follow-up for Over 20 Years of a Patient With Ischemic Heart Disease After Diagnosis of Chronic Total Occlusion of the 3 Main Coronary Arteries

A 48-year-old man suffered from acute coronary syndrome in 1978. Coronary angiography was performed at that time and showed 99% stenosis of the right coronary artery, 100% of the left circumflex branch, and 50% of the left ascending artery. He received conservative therapy. Five years later (ie, 1983), coronary angiography showed complete occlusions of the 3 major coronary arteries. Rich collateral circulation had developed distal to all 3 major coronary trees. The patient and his family rejected invasive therapies such as coronary-artery bypass graft or percutaneous coronary intervention. Cardiac catheterizations were performed in 1996, 2001, and 2007, but angiographic follow-up studies showed no change in either the coronary atherosclerosis or the collateral circulation. The left ventricular ejection fraction has been maintained at >60%. During the 20-year follow-up, he has had refractory angina, but has not suffered from acute coronary syndrome, congestive heart failure, or critical arrhythmia.

Clinical and angiographic results of percutaneous coronary revascularization using a trilayer stainless steel‐tantalum‐stainless steel phosphorylcholine‐coated stent: The TriMaxx trial

The TriMaxx coronary stent system includes a novel trilayer metal stent having two outer layers of 316L stainless steel and with an inner 0.0007 inches layer of tantalum. This enables creation of a maximally flexible and thin device (0.0029 inches) while still maintaining the requisite strength and radiopacity for effective implantation. The objective of this multi-center, single-arm prospective clinical trial was to assess the safety and performance of the TriMaxx stent for the treatment of single de novo coronary artery lesions. One hundred patients with ischemic coronary occlusive disease because of single de novo obstructive lesions of native coronary arteries were treated with 3 x 15 or 3 x 18 mm TriMaxx stents in four hospitals in Brazil and Germany between May of 2004 and September of 2005. An independent core laboratory analyzed the quantitative coronary angiography (QCA) results immediately after stent implantation, and after six months. The lesion, procedure, and device-deployment success rates were 100, 99, and 100%, respectively. Eighty-eight patients underwent follow-up angiography at 6 +/- 1 months. After six months, 13 (13%) of patients had sustained major adverse cardiac events, including 9.0% that required target lesion revascularization (TLR). The follow-up angiographic studies revealed a binary in-stent restenosis rate of 25% with in-stent late lumen loss of 0.94 +/- 0.57 mm. These results demonstrate that the TriMaxx stent can be safely deployed for the treatment of single de novo coronary occlusive lesions with six-month clinical and angiographic results rates comparable to historical results using other bare metal stents.

Syndrome de vasoconstriction cérébrale segmentale réversible ou angéite primitive du Systeme nerveux central?

Reversible Cerebral Vasoconstriction Syndrome (RCVS) may present as thunderclap headache (TCH), accompanied by reversible cerebral vasospasm and focal neurological deficits, often without a clear precipitant. RCVS may be mistaken for Primary Angiitis of the Central Nervous System (PACNS) due to the presence of similar angiographic features of segmental narrowing of cerebral arteries. We discuss the clinical features of a young female migraine patient who developed TCH and was found to have RCVS following initial treatment with corticosteroids for PACNS, in the context of a systematic review of the available medical literature. A Medline search was performed to identify all case reports since 1966 describing RCVS and PACNS that provide sufficient clinical detail to permit diagnostic classification according to published criteria. RCVS included case studies in which there was angiographic or transcranial Doppler ultrasound evidence of near-to-complete resolution of cerebral vasoconstriction in the absence of a well-recognized secondary cause. PACNS included reports of histologically confirmed PACNS either through biopsy or necropsy. Reversible Cerebral Vasoconstriction Syndrome occurs primarily in females and is characterized by sudden, severe headache at onset, normal CSF analysis, vasoconstriction involving the Circle of Willis and its immediate branches, and angiographic or TCD ultrasound evidence of near-to-complete vasospastic resolution within 1-4 weeks. It occurs typically in the context of vasoconstrictive drug use, the peripartum period, bathing, and physical exertion. Initial and follow-up (within 4 weeks) non-invasive angiographic studies are indicated in patients who present with TCH or who have clinical presentations that could be consistent with RCVS or PACNS in the absence of a well-recognized secondary cause, such as subarachnoid haemorrhage. Early reversibility of cerebral vasospasm is the key neuroradiological feature that supports the clinical diagnosis of RCVS.

Surgical treatment of myocardial bridging: report of 31 cases

Myocardial bridging (MB) is usually considered a benign condition but may result in myocardial ischemia, myocardial infarction (MI), exercise-induced tachycardia, atrioventricular conduction block or even sudden cardiac death. This retrospective study summarizes our operative methods and outcomes for treatment of 31 cases of MB. From January 1997 to December 2006, 31 consecutive patients (24 men and 7 women; aged 35 - 67 years; mean 52.3 years) with MB underwent surgical treatment. Thirteen patients had MB only and 18 patients had MB associated with other heart diseases. In preoperative cardiac function grading, 5 patients were in NYHA class I and 18 in NYHA class II and 8 in NYHA class III. Among them, 15 underwent myotomy and 16 underwent coronary artery bypass grafting (CABG). All patients survived and recovered uneventfully. Neither hospital or late death nor major complications occurred. Postoperative exercise testing in all patients failed to reveal any persistent ischemia. Follow-up time was 3 - 115 months (mean 31 months). Follow-up angiographic studies in 21 patients (68%) demonstrated restoration of coronary blood flow and myocardial perfusion without significant residual compression of the artery. All patients were symptom-free and currently in NYHA class I - II. The patients who are refractory to medication should actively undergo the surgical procedures such as myotomy and CABG. Myotomy should be advocated as the first choice because of its safety and satisfactory results.

MIDTERM CLINICAL AND MAGNETIC RESONANCE IMAGING FOLLOW-UP OF LARGE AND GIANT CAROTID ARTERY ANEURYSMS AFTER THERAPEUTIC CAROTID ARTERY OCCLUSION

The purpose of this study was to evaluate aneurysm size and clinical symptoms midterm after therapeutic carotid artery occlusion in 39 patients with large or giant carotid artery aneurysms. Between January 1996 and August 2004, 39 patients with large or giant carotid artery aneurysms were treated with therapeutic carotid artery occlusion and had clinical and magnetic resonance imaging follow-up of at least 3 months (mean, 35.9 mo; median, 29 mo; range, 3-107 mo; 117 patient-yr). Initial clinical presentation was mass effect caused by the aneurysm in 32 (82%) of the 39 patients. Three patients presented with subarachnoid hemorrhage and one presented with epistaxis; two aneurysms were an incidental finding and one was additional to another ruptured aneurysm. There were no early or late complications of therapeutic carotid artery occlusion. All aneurysms seemed to have thrombosed completely after carotid artery occlusion as observed on early and late magnetic resonance imaging and magnetic resonance angiographic follow-up studies. At the time of the most recent magnetic resonance imaging follow-up study, 29 (74%) of the 39 aneurysms involuted totally, two aneurysms decreased to 25% of the original diameter, two aneurysms decreased to 50%, and five aneurysms decreased to 75%. Two aneurysms remained unchanged in size after 49 and 58 months, respectively. At the most recent clinical follow-up evaluation, symptoms of mass effect were cured in 19 (60%), improved in 10 (31%), and remained unchanged in three (9%) of the 32 patients. Therapeutic carotid artery occlusion was a simple, safe, and effective treatment for large and giant carotid artery aneurysms. Almost all aneurysms involute completely or substantially decrease in size. Alleviation of symptoms of mass effect was achieved in most patients.

Stent fracture and restenosis after placement of a drug-eluting device in the vertebral artery origin and treatment with the stent-in-stent technique

The authors report two cases of stent fracture and restenosis after placement of a drug-eluting device in the vertebral artery (VA) origin, and describe management of restenosis with the stent-in-stent technique. Two women, one 62 and the other 67 years of age, underwent stent placement in the VA origin to treat symptomatic and angiographically significant stenosis in this vessel. Sirolimus-eluting coronary stents (Cypher) were used in both cases. Four months after placement of the devices, the symptoms recurred. Follow-up angiography performed 5 months after insertion of the devices revealed a transverse stent fracture with separation of the fragments and severe in-stent restenosis in both cases. The restenoses were treated with reinsertion of coronary stents (Cypher and Jostent FlexMaster) by using the stent-in-stent technique. After stent reinsertion, the patients exhibited relief of symptoms. This paper is the first report of fracture in a drug-eluting stent and restenosis after stent placement in the VA origin. Restenosis caused by such a fracture can be managed successfully by performing the stent-in-stent maneuver. The physical properties of metallic devices, stent strut geometry, and anatomical peculiarities of the subclavian artery may be associated with stent fractures. Earlier follow-up angiography studies (within 6 months) are warranted.

Balloon-Assisted Coil Embolization

Object. The aim of this study was to assess the incidence, indications, complications, and angiography results associated with balloon-assisted coil embolization (BACE) of intracranial aneurysms and to compare these factors with those for conventional coil embolization (CE). Methods. Between 1995 and 2005, 827 intracranial aneurysms in 757 consecutive patients were packed with coils. Balloon-assisted coil embolization was used in 8.6% (71 of 827) of the coil insertion procedures and was more frequently used in large aneurysms, un-ruptured lesions, and those located on the vertebrobasilar system and carotid artery. Procedure-related complications leading to death or dependency were significantly higher in BACEs (14.1%) compared with those in CEs (3%). Packing densities and the results of 6-month follow-up angiography studies did not differ significantly between the two types of treatments. There was a strong trend for a higher retreatment rate in the aneurysms treated with BACE. Conclusions. Balloon-assisted coil embolization of intracranial aneurysms is associated with a high complication rate and should only be used if conventional CE of these lesions is impossible or has failed and if anticipated surgical risks are too high. The BACE procedure does not improve the occlusion rates of the aneurysms on follow-up evaluation.

Subtotal obliteration of cerebral arteriovenous malformations after Gamma Knife surgery

Subtotal obliteration of cerebral arteriovenous malformations (AVMs) after Gamma Knife surgery (GKS) implies a complete angiographic disappearance of the AVM nidus but persistence of an early filling draining vein, indicating that residual shunting is still present; hence, per definition there is still a patent AVM and the risk of bleeding is not eliminated. The aim of this study was to determine the risk of hemorrhage for patients with subtotal obliteration of AVMs. After GKS for cerebral AVMs, follow-up angiography demonstrated a subtotally obliterated lesion in 159 patients. Of these, in 16 patients a subtotally obliterated AVM developed after a second GKS was performed for the partially obliterated lesion. The mean age of these patients was 35.2 years at the time of the diagnosis of subtotally obliterated AVMs. The lesion volumes at the time of initial GKS treatment ranged from 0.1 to 11.5 cm3 (mean 2.5 cm3). The mean peripheral dose used in the 175 GKS treatments was 22.5 Gy (median 23 Gy, range 15-31 Gy). To achieve total obliteration of the AVM, 23 patients underwent a new GKS targeting the proximal end of the early filling vein. The mean peripheral dose given in these cases was 23 Gy (median 24, range 18-25 Gy). The incidence of subtotally obliterated AVMs was 7.6% from a total of 2093 AVMs treated and in which follow-up imaging was available. The diagnosis of subtotally obliterated AVMs was made a mean of 29.4 months (range 4-178 months) after GKS. The number of patient-years at risk (from the time of the diagnosis of subtotally obliterated AVMs until either the confirmation of a total obliteration of the lesion on angiography or the time of the latest follow-up angiographic study that still visualized the early filling vein) was a mean of 3.9 years, ranging from 0.5 to 13.5 years, and a total of 601 patient-years. There was no case of bleeding after the diagnosis of subtotally obliterated AVMs. Of 90 patients who did not undergo further treatment and in whom follow-up angiography studies were available, the same early filling veins still filled in 24 (26.7%), and the subtotally obliterated AVMs were subsequently obliterated in 66 patients (73.3%). In 19 patients who underwent repeated GKS for subtotally obliterated AVMs and in whom follow-up angiography studies were available, the AVMs were obliterated in 15 (78.9%) and remained patent in four (21.1%). The fact that none of the patients with subtotally obliterated AVMs suffered a rupture is not compatible with the assumption of an unchanged risk of hemorrhage for these lesions, and implies that the protection from rebleeding in patients with subtotal obliteration is significant. Subtotal obliteration does not necessarily seem to be a stage of an ongoing obliteration. At least in some cases it represents an end point of this process, with no subsequent obliteration occurring. This observation requires further confirmation by open-ended follow-up imaging.

Off-pump coronary artery bypass sacrifices graft patency: Meta-analysis of randomized trials

Off-pump coronary artery bypass sacrifices graft patency: Meta-analysis of randomized trials

Additional Rescue Stent Placement for Stabilization of a Prolapsed Coil during Stent-Assisted Coil Embolization of a Wide-Neck Intracranial Aneurysm

We report a case of a 55-year-old man carrying two unruptured internal carotid artery (ICA) wide-neck aneurysms. In the same session, the smaller aneurysm was treated by coils using the remodeling technique and the large aneurysm was treated by stent-assisted coil embolization. During the stent-assisted procedure for the large aneurysm, the microcatheter tip moved from the aneurysm into the parent artery causing a prolapse of some coil loops into the vessel lumen. The distal part of the coil was tangled within the stent's struts, therefore, in order to introduce the entire coil, an attempt was made to withdraw the prolapsed loops of the coil within the microcatheter and concomitantly repositioning the microcatheter into the residual aneurysm neck through the stent struts. However this maneuver was unsuccessful. An attempt to retrieve gently the coil also failed and the coil prematurely detached. For maintaining the patency of the arterial lumen and to reduce the embolic risk, a second stent was used to pin the free coil loops. The rescue stent was positioned within the coil loops and its deployment allowed a circumferential expansion of some loops around the stent perimeter while other loops were flattened against the wall of the artery. The parent artery remained patent at one-year follow-up angiographic study. No clinical complications were observed.

Balloon-assisted coil embolization of intracranial aneurysms: incidence, complications, and angiography results

The aim of this study was to assess the incidence, indications, complications, and angiography results associated with balloon-assisted coil embolization (BACE) of intracranial aneurysms and to compare these factors with those for conventional coil embolization (CE). Between 1995 and 2005, 827 intracranial aneurysms in 757 consecutive patients were packed with coils. Balloon-assisted coil embolization was used in 8.6% (71 of 827) of the coil insertion procedures and was more frequently used in large aneurysms, unruptured lesions, and those located on the vertebrobasilar system and carotid artery. Procedure-related complications leading to death or dependency were significantly higher in BACEs (14.1%) compared with those in CEs (3%). Packing densities and the results of 6-month follow-up angiography studies did not differ significantly between the two types of treatments. There was a strong trend for a higher retreatment rate in the aneurysms treated with BACE. Balloon-assisted coil embolization of intracranial aneurysms is associated with a high complication rate and should only be used if conventional CE of these lesions is impossible or has failed and if anticipated surgical risks are too high. The BACE procedure does not improve the occlusion rates of the aneurysms on follow-up evaluation.