Angiographic Improvement Research Articles

Spatial coefficient of variation applied to arterial spin labeling MRI may contribute to predict surgical revascularization outcomes in pediatric moyamoya vasculopathy.

In moyamoya vasculopathy, prolonged arterial transit time may increase the arterial spin labeling (ASL) signal heterogeneity, which can be quantitatively expressed by the spatial coefficient of variation of ASL-CBF (ASL-sCoV). The aim was to compare the accuracy of ASL-sCoV and ASL-CBF with dynamic susceptibility contrast (DSC)-CBF and time-to-peak (DSC-TTP) in the evaluation of perfusion changes and clinical outcome after encephalo-duro-arterio-myo-synangiosis (EDAMS) in pediatric moyamoya patients. A total of 37 children with moyamoya vasculopathy (mean age 6.31years (1.12-15.42)) underwent ASL and DSC perfusion imaging at 3T before and up to 24months after EDAMS. Mean DSC-CBF, mean DSC-TTP, mean ASL-CBF, and ASL-sCoV were calculated in middle cerebral artery territories. Generalized linear model analyses were used to evaluate temporal variations of postoperative perfusion changes and to compare these variations between patients developing valid pial collateralization and those without angiographic improvement. Relationship between perfusion parameters and clinical outcome after surgery was tested using multivariate regression analysis. Significant reduction was observed after EDAMS for ASL-sCoV (P = .002; eta-squared (η2) = 0.247) and DSC-TTP (P < .001; η2 = 0.415), whereas only a trend of increase was observed for DSC-CBF and ASL-CBF, with larger discrepancy before and 6months after surgery. At last follow-up, children developing pial collateralization showed lower absolute ASL-sCoV (P = .002 Cohen's d = 0.84) and DSC-TTP (P = .027; Cohen's d = 0.64) and higher DSC-CBF (P = .002; Cohen's d = - 0.55) compared with those without vascular improvement. Low preoperative and early post-surgical ASL-sCoV predicted better long-term neurological outcome (P < .001; ß = - 0.631). ASL-sCoV may contribute to predict surgical outcomes in pediatric moyamoya patients undergoing EDAMS.

Abstract No. 455 Customized patient-specific three-dimensional printed pediatric renovascular phantom for complex renal artery stenosis preprocedural planning: “plug and play”

The renal artery ostial anatomy, balloon profile and stent deployment are all elements of complex procedural RAS planning in children. This study aims to establish the feasibility of performing simulated renovascular intervention on a 3D printed pediatric RAS endovascular phantom. The first iteration of this phantom contained a normal nonremovable renovascular system. This iteration is upgraded to a removable patient tailored specific RAS “plug and play” module facilitating pre procedure planning. Silicone poured in 3D printed molds were created from the patient’s CT. An additional upper extremity vascular access point was added and a pump was installed to simulate circulatory flow. Models: patient- specific left inferior branch high-grade RAS (80%) and bilateral RAS (63% and 45%) with steep ostial angle Simulation steps: catheter and balloon entry via upper and lower extremity, selective renal angiography, stenosis identification and transgression, cutting balloon angioplasty and balloon expandable stent simulation. Operators completed a 10 point questionnaire, rating their experience using a 5-point Likert scale (1-Strongly disagree to 5-Strongly agree). Upper extremity approach was deemed necessary for selective renal catheterization due to the steep renal artery ostial angulation. Case 1: Left proximal RAS stenting was performed using 5 x 8 mm and 5 x 15 mm Viabahn balloon-expandable stents. Case 2: Right RAS (45%) 3x10 mm cutting balloon angioplasty followed by placement of a 3 x 8 mm balloon-expandable stent. Significant angiographic improvement was noted post procedure in both cases. Three operators had good agreement (k = 0.46) that the 3D printed phantom is helpful in procedure planning, skill development and provides a realistic experience from catheterization to stenting. The simulation resulted in a planned live patient brachial access. To our knowledge this is the first pediatric renovascular phantom using a patient-specific removable model. This platform can provide patient focused simulation for renal arterial approach, balloon stricture negotiation, stent sizing and deployment, all complex elements of this procedure in children.

On the role of balloon angioplasty in infantile and childhood coarctation of aorta

Balloon angioplasty (BA) for ‘native’ coarctation of the aorta (CoA) in infants and young children remains controversial. In this study, the aim is to evaluate the immediate and mid-term outcome of BA. MethodsA prospective, interventional study conducted in a tertiary, high volume cardiac centre, over a 30-month period, ending May 2017. BA was preceded by preoperative clinical examination, and a detailed cardiac ultrasound and catheterization assessment. A statistical analysis was performed – including logistic regression and Kaplan–Meier tests. ResultsThe study included 74 patients with a median age of 10 months (inter-quartile range – IQR, 5–61) BA was ‘successful’ in 66 (89%) cases, with a decrease in peak pressure gradient (PG) and an angiographic improvement of 59% (95% confidence interval – CI, 56–63; P<0.001) and 85% (95% CI, 83–87; P<0.0001), respectively. Recurrence was reported in 19 (26%) cases. Long-segment CoA was the best predictor of recurrence (adjusted OR, 72; 95% CI, 4–1295; P=0.004). BA was most ‘durable’ in those older than 12 months – 88% of those older than 12 months had freedom from recurrence. The mean time-to-event was 25 months (95% CI, 22–28). Ileofemoral artery occlusion was the most common complication (n=5; 7%), followed by dissection (n=4; 5%). ConclusionsBA is a feasible option to treat native CoA in infants and children, with good immediate and mid-term outcomes. This study contributes to the growing body of information, supporting the role and effectiveness of BA in this setting.

Improved regional myocardial blood flow and flow reserve after coronary revascularization as assessed by serial 15O-water positron emission tomography/computed tomography.

Myocardial perfusion imaging without and with quantitative myocardial blood flow (MBF) and myocardial flow reserve (MFR) plays an important role in the diagnosis and risk stratification of patients with stable coronary artery disease (CAD). We aimed to quantify the effects of coronary revascularization on regional stress MBF and MFR and to determine whether the presence of subendocardial infarction was associated with these changes. Forty-seven patients with stable CAD were prospectively enrolled. They underwent 15O-water positron emission tomography at baseline and 6 months after optimal medical therapy alone (n = 16), percutaneous coronary intervention (PCI) (n = 18), or coronary artery bypass grafting (CABG) (n = 13). Stenosis of ≥50% diameter was detected in 98/141 vessels (70%). The regional MFR was significantly increased from baseline to follow-up [1.84 (interquartile range, IQR 1.28-2.17) vs. 2.12 (IQR 1.69-2.63), P < 0.001] in vessel territories following PCI or CABG due to an increase in the stress MBF [1.33 (IQR 0.97-1.67) mL/g/min vs. 1.64 (IQR 1.38-2.17) mL/g/min, P < 0.001], whereas there was no significant change in the regional stress MBF or MFR in vessel territories without revascularization. A multilevel mixed-effects models adjusted for baseline characteristics, subendocardial infarction assessed by cardiovascular magnetic resonance imaging, and intra-patient correlation showed that the degree of angiographic improvement after coronary revascularization was significantly associated with increased regional stress MBF and MFR (P < 0.05 for all). Coronary revascularization improved the regional stress MBF and MFR in patients with stable CAD. The magnitude of these changes was associated with the extent of revascularization independent of subendocardial infarction.

Abstract TP548: Stent Retrievers as a Novel Treatment Tool for Refractory Cerebral Vasospasm

Introduction: Cerebral vasospasm commonly contributes to morbidity in patients who survive aneurysmal subarachnoid hemorrhage. When vasospasm becomes refractory to medical management, endovascular treatment options include intraarterial (IA) vasodilator injections and/or balloon angioplasty. However, IA vasodilators often provide limited angiographic improvements and can cause secondary systemic hypotension. Limitations of balloon angioplasty include restricted use to proximal vessels, risk of rupture with balloon inflation, and temporary vessel occlusion. Methods: We report our initial experience on the use of stent retrievers for five cases of refractory vasospasm. After injecting IA nicardipine and noting minimal angiographic improvement, we deployed the stent retriever for two minutes before the stent was re-sheathed. Results: We show safe and successful angiographic resolution of vasospasm in all cases, with a representative angiography shown in Figure 1. Injection of the left vertebral artery shows vasospasm along the basilar (BA) and posterior cerebral arteries (PCA) (Fig 1A). Narrowing improves significantly after stent deployment in the left PCA and BA (Fig 1B). There were no procedural complications. Conclusion: Stent retrievers have several benefits over balloon angioplasty for treatment of vasospasm. Stent retrievers are non-occlusive, conform easily to the curvature of the vessel, and have a known, safe opening force that prevents vessel rupture. In contrast to balloon angioplasty, stent retrievers have limited surface interface with the lumen, theoretically resulting in less endothelial injury. Lastly, most endovascular surgeons have more technical experience with stent retrievers given its widespread use in mechanical thrombectomy. In summary, stent retrievers can be used as a facile, safe, and effective endovascular treatment and should be considered as one of the emerging therapies for refractory cerebral vasospasm.

Balloon Angioplasty and Stenting for Unilateral Branch Pulmonary Artery Stenosis Improve Exertional Performance

ObjectivesThis study sought to determine whether pulmonary artery intervention in patients with unilateral proximal pulmonary artery stenosis (PAS) improves exercise capacity, abnormal ventilatory response to exercise, and symptoms. BackgroundStenosis of the branch pulmonary arteries results in pulmonary blood flow maldistribution (PBFM). The resulting ventilation–perfusion mismatch is associated with an increased ventilatory response to exercise and decreased exercise capacity. It is unclear if technical success in relieving branch PAS translates to clinical improvement in exercise capacity and ventilatory response. MethodsTwenty patients with biventricular circulation and a minimum 10% PBFM who underwent transcatheter relief of PAS were enrolled in a multi-institutional prospective cohort study. Pre- and post-procedure assessment of the degree of PBFM, exercise capacity, ventilatory response to exercise, and subjective assessment of breathlessness were collected and analyzed. ResultsTechnical success was achieved in all patients with significant angiographic improvement in minimal lumen diameter (p = 0.001) and peak gradient (p = 0.001). Median PBFM improved (19.5% [range 12.0% to 31.0%] before vs. 7.0% [range 0% to 33.0%] after; p = 0.003). Exercise capacity was low at baseline and improved significantly post-intervention; percent predicted peak oxygen consumption improved from 70% (range 45% to 96%) to 83% (range 47% to 121%) (p = 0.02). Percent predicted oxygen pulse improved (p = 0.02). Ventilatory response to exercise improved; ventilatory equivalent of carbon dioxide slope post-intervention decreased to 29.3 versus 32.5 pre-intervention (p = 0.01). Subjective assessment of dyspnea improved. Five patients with minimal improvement in PBFM also showed minimal improvement in exercise parameters. ConclusionsSuccessful relief of unilateral branch PAS results in significant improvements in exercise capacity, ventilatory efficiency, and symptoms.

Aqueous Angiographic Outflow Improvement after Trabecular Microbypass in Glaucoma Patients

To study changes in aqueous humor outflow (AHO) patterns after trabecular micro-bypass (TMB) in glaucoma patients using intraoperative sequential aqueous angiography. Prospective comparative case series. Fifteen subjects (14 with glaucoma and 1 normal). Sequential aqueous angiography (Spectralis HRA+OCT; Heidelberg Engineering) was performed on fourteen glaucoma patients undergoing routine TMB (iStent Inject; Glaukos Corporation) and cataract surgery and one normal patient undergoing cataract surgery alone. Indocyanine green (ICG) aqueous angiography established initial baseline nasal angiographic AHO patterns. Two TMB stents were placed in regions of baseline low or high angiographic AHO in each eye (n = 2 eyes with enough space to place two stents in both low angiographic regions; n = 8 eyes with two stents both placed in high angiographic regions; n = 4 eyes with enough space to place one stent in a low angiographic region and the other stent in a high angiographic region). Subsequent fluorescein aqueous angiography was utilized to query alterations to angiographic AHO patterns. Angiographic signal and patterns before and after TMB. At baseline, all eyes showed segmental angiographic AHO patterns. Focused on the nasal hemisphere of each eye, for each stent TMB in initially low ICG angiographic signal regions showed transient or persistently improved fluorescein angiographic signal (11.2-fold; p = 0.014). TMB in initially high ICG signal regions led to faster development of fluorescein angiographic patterns (3.1-fold; p = 0.02). TMB resulted in different patterns of aqueous angiographic AHO improvement whose further understanding may advance basic knowledge of AHO and possibly enhance intraocular pressure reduction after glaucoma surgery in the future.

Comparison of 577-nm Multispot and Standard Single-Spot Photocoagulation for Diabetic Retinopathy

Objective: To compare two different laser strategies of panretinal photocoagulation for diabetic retinopathy. Methods: Single-center, randomized study including 41 eyes treated with 577-nm multispot laser with a 20-ms pulse duration (group 1) or a 532-nm single-spot laser with a 100-ms pulse duration (group 2). The outcomes included best-corrected visual acuity (BCVA) and imaging changes at baseline, 6 and 12 months, laser parameters, and results of subjective pain analysis. Results: At 12 months, the treatments did not differ significantly in BCVA, central retinal thicknesses (CRTs), improved macular edema, vitreomacular interface changes, patient-reported pain scores, or angiographic responses. Group 1 had significantly fewer treatment sessions but used more laser spots (p < 0.001). Conclusion: The multispot laser required fewer applications with more spots delivered to compensate for lower fluency, showing similar patient tolerance to single-spot laser. Both groups maintained the initial visual acuities and CRTs; about 50% of cases had vitreomacular interface changes and improved macular edema, with similar angiographic improvements after 12 months.

Early Natural History of Spontaneous Coronary Artery Dissection.

Risks and mechanisms of extension of conservatively managed spontaneous coronary artery dissection (SCAD) remain incompletely understood. Study objectives were to (1) evaluate mechanisms of early SCAD evolution through serial angiographic analysis, and (2) determine predictors of early SCAD progression. Retrospective registry study of patients with SCAD managed with an initial conservative strategy (n=240). Patients who experienced significant SCAD progression within 14 days, defined as clinical worsening plus new critical coronary obstruction on repeat angiography, were compared with remaining controls. A total of 42 of 240 (17.5%) experienced significant SCAD progression after index conservative approach; 91% by day 6. Isolated intramural hematoma (IMH) at baseline (no intimal dissection) was observed more frequently in those experiencing progression compared with controls (69.1% versus 44.4%; P=0.004). Multivariable predictors of SCAD progression included lesion severity, multivessel involvement, and isolated IMH. To investigate mechanisms of SCAD evolution, all repeat angiograms ≤14 days were compared with corresponding baselines (n=82 patient angiogram pairs). Of those with isolated IMH at baseline, 20% developed intimal dissection at repeat study. IMH was associated with greater longitudinal lesion extension (11.5 versus 2.8 mm; P=0.01), worsening Thrombolysis in Myocardial Infarction flow (-0.8 versus 0.1; P=0.003), and a nonsignificant lower rate of angiographic improvement (20.0% versus 31.3%; P=0.16) compared with the group with baseline intimal dissection. Optical coherence tomography subgroup analysis (n=17) indicated intimo-medial thickness to be lowest at the midpoint of IMH. Conservatively managed SCAD carries a 1:6 hazard for serious deterioration within 6 days. The risk was higher in those with isolated IMH at baseline. IMH often precedes development of intimal dissection, which has implications for mechanisms of SCAD.

Intra-Arterial Papaverine-Hydrochloride and Transluminal Balloon Angioplasty for Neurointerventional Management of Delayed-Onset Post-Aneurysmal Subarachnoid Hemorrhage Vasospasm

After subarachnoid hemorrhage, delayed onset vasospasm can result in devastating ischemic stroke. The phenomenon of delayed cerebral ischemia (DCI) is not yet fully understood, and the correlation of angiographic vasospasm and cerebral infarction is still unclear. Therefore, we investigated the effect of endovascular treatment on the angiographic response and occurrence of DCI. Eighty patients with subarachnoid hemorrhage and serious cerebral vasospasm underwent endovascular treatment using intra-arterial papaverine-hydrochloride (IAP) or transluminal balloon angioplasty (TBA). The angiographic response and infarction rate were classified using the pre- and postinterventional angiographic images and computed tomography scans. In 90% of patients, vasospasm could be improved. In most cases (78.8%), IAP was used. Retreatment after IAP was necessary in 32.9% of patients but never after TBA. A total of 233 vascular territories were treated in 128 procedures. Angiographic improvement was observed in 66.5% of territories, which was significantly associated with early intervention (P= 0.02), the use of TBA (P= 0.01), and the dose of papaverine-hydrochloride (P= 0.01). DCI occurred in 47.5% of the patients. Territorial infarction was associated with a poor Hunt and Hess grade (P= 0.03), day of aneurysm treatment (P= 0.01), severe vasospasm before (P= 0.02) and after (P= 0.03) treatment, and number of interventions (P= 0.01). However, the infarction rate was independent of the angiographic response. The discrepancy of excellent angiographic results and the high incidence of DCI might stem from an inaccurate or a delayed diagnosis of impending ischemia. In view of the limited time window, optimized peri-interventional management and continuous cerebral multimodality neuromonitoring might be crucial for the ideal timing of endovascular procedures to prevent cerebral infarctions.

Chemical angioplasty for medically refractory reversible cerebral vasoconstriction syndrome

Purpose: Medically refractory reversible cerebral vasoconstriction syndrome (RCVS), a rare variant of RCVS, poses a significant therapeutic challenge. Herein we describe a case of medically refractory RCVS that required treatment with intra-arterial (IA) verapamil and subsequent nimodipine, resulting in both angiographic and clinical improvement after failing to respond to hemodynamic augmentation. We also supplement a description of our case with a review of other case studies and case series in which IA calcium channel blockers were used to treat RCVS. We propose that the case we outline below demonstrates that neurointerventional management with IA verapamil is appropriate and effective as an early intervention of medically refractory RCVS.Methods and Materials: Using PubMed and Google Scholar, we performed a search of the English language literature with several combinations of the keywords “intra-arterial”, “calcium channel blockers”, “reversible cerebral vasoconstriction syndrome”, “RCVS”, “nimodipine”, “verapamil”, “milrinone”, and “nicardipine” to identify studies in which RCVS was treated with IA calcium channel blockers.Results: We identified eight case studies and case series that met our inclusion criteria. Eighteen patients are encompassed in these eight studies.Conclusions: IA administration of calcium channel blockers has been shown to return cerebral vessels to their normal caliber in patients with medically refractory RCVS. However, there are no randomized controlled trials of the treatment of RCVS, and further studies are needed to elucidate the optimal treatment protocol for medically refractory RCVS.

Abstract WP128: A Long Term Treatment Outcomes of Middle Cerebral Artery Stenosis Patients Treated With Medical Therapy

Purpose: Little is known about the long term clinical outcomes of middle cerebral artery (MCA) stenosis / occlusion patients who are treated with medical therapy. The efficacy and safety of the medical treatment was evaluated by analyzing the clinical outcomes along and imaging analysis using CT Angiography (CTA) with an automatic measurement software. Methods: Patients who were diagnosed with middle artery stenosis or occlusion were prospectively enrolled in the study. Those who were diagnosed with moyamoya disease were excluded. Along with the rigorous medical treatment for atherosclerosis risk factors, Cilostazol 200mg/day was selected as the first line of medication, and switched to either aspirin 100mg/day or clopidogrel 75mg/day if necessary. CT Angiogram (CTA) was performed and a software for the measurement of stenosis on the stretched view was used for evaluating the degree of stenosis. The neurological findings as well as the degree of stenosis during the observation time were analyzed. Results: Of the 186 MCA stenosis / occlusion patients who visited our institution, 62 lesions in 60 patients who completed periodic CTA evaluation were selected for the study. 20 lesions (40.3%) were symptomatic at the time of diagnosis. 45 patients (75.0%) were treated with cilostazol and 22 (36.7%) underwent dual antiplatelet therapy. 7 patients (11.7%) were observed without any antiplatelet therapy. During the median observation time of 75.6 months, 24 patients (40.0%) showed angiographic improvement, and the median % area stenosis improved from 66.0% (IQR: 53.0 - 80.0) to 54.7% (48.6 - 77.5). Of the 29 patients who showed complete occlusion at the initial diagnosis, 17 (58.6%) showed any degree of recanalization. For those with symptomatic lesions, no patient developed major stroke on the ipsilateral side after completing the 3 months of initial treatment. Conclusions: Angiographic improvement of MCA stenosis was observed with successful prevention of major stroke associated with the disease. Majority of the patients who tolerated the complete occlusion at the time of initial treatment showed recanalization during the observation period. Medical treatment can be an effective therapeutic method for the MCA stenosis / occlusion patients.

Long-term follow-up of patients with Buerger's disease after autologous stem cell therapy.

Objective:We investigated the long-term results of autologous bone marrow mononuclear cells (ABMMNCs) implantation in patients with Buerger’s disease (BD).Methods:Twenty-eight patients (25 males and 3 females) who had BD and critical unilateral limb ischemia were investigated between April 2003 and August 2005. The patients were administered multiple injections of CD34+ and CD45+ positive ABMMNCs into the gastrocnemius muscle, the intermetatarsal region, and the dorsum of the foot (n=26) or forearm (n=2) and saline injection into the contralateral limb.Results:The mean follow-up time was 139.6±10.5 months. No complication related to stem cell therapy was observed during the follow-up. The ankle–brachial pressure index evaluated at 6 months and 120 months was compared to the baseline scores (p<0.001 and p=0.021, respectively). Digital subtraction angiography (DSA) was performed for all patients at baseline, 6 months, and 120 months. The angiographic improvement was 78.5% and 57.1% at 6 and 120 months, respectively. Patients demonstrated a significant improvement in the quality of life parameters at 6 months compared to baseline (p=0.008) and 120 months compared to the baseline (p=0.009). The 10-year amputation-free rate was 96% (95% CI=0.71-1) in ABMMNC-implanted limbs and 93% (95% CI=0.33–0.94) in saline-injected limbs (p=1).Conclusion:Autologous stem cell therapy could be an alternative therapeutic method for BD at long-term follow-up.

ACCP Virtual Poster Symposium

<scp>ACCP</scp> Virtual Poster Symposium

Chemical angioplasty with spasmolytics for vasospasm after subarachnoid hemorrhage.

Clinically symptomatic vasospasm leading to delayed ischemic neurological deficits occurs in up to 30% of patients with subarachnoid hemorrhage (SAH). Vasospasm can result in a serious decline in clinical conditions of patients with SAH, yet the algorithm for vasospasm treatment and prevention remains unclear. Intra-arterial administration of vasodilators is one of the modalities used for vasospasm therapy. Over the last 7years, we have treated 27 female and 7 male patients with vasospasm using intra-arterial administration of either nimodipine or milrinone; all had suffered aneurysm rupture. Of these patients, 28 were treated surgically (clip), and 6 patients had their aneurysm coiled. Spasmolytics were applied from day 2 to day 18 after rupture. Of the 53 procedures, angiographic improvement was documented in 92% of cases with a mean flow velocity decrease of 65cm/s. Brain metabolism changes were monitored after the procedure. The highest level of immediate clinical improvement was observed in conscious patients with a focal neurological deficit (aphasia, hemiparesis). Overall clinical outcomes (Glasgow outcome scale, GOS) were as follows: GOS 5 (12 patients), GOS 4 (5 patients), GOS 3 (5 patients), GOS 2 (6 patients), and GOS 1 (6 patients). Intra-arterial administration of spasmolytics is a safe and potent method of vasospasm treatment. It is most effective when applied to conscious patients with a focal deficit. For unconscious patients, its therapeutic benefits are inconclusive. Patients in severe clinical states would further require use of other diagnostic tools such as multimodal brain monitoring to complement vasospasm therapy.

Abstract TP213: Initial Vascular Lesion Patterns on Early Images Would Predict Vascular Outcomes in Acute Cerebral Artery Dissection

Introduction: Imaging characteristics and prognosis on the follow-up imaging in patients with acute cervicocerebral artery dissection are not well established. Hypothesis: Initial lesion patterns on early vascular imaging would predict vascular imaging outcomes in acute cervicocerebral artery dissection. Methods: Individual clinical data and imaging features were obtained from 167 consecutive patients who presented with acute ischemic symptoms or headache due to cervicocerebral artery dissection. Patients were categorized according to their baseline vascular imaging features as either Stenosis Only, Aneurysm Only, or Both Stenosis and Aneurysm. The angiographic characteristics and improvements of early vascular lesions between baseline (within 7 days after symptoms onset) and follow-up vascular images (6-month or 1-year after symptom onset) were compared. Results: A total of 76 patients who underwent baseline and 6-month or 1-year vascular imaging were included. Patients in the Stenosis Only group (n=36) were younger (mean age, 45±11) than those in the Aneurysm Only (n=9, 55±7) and Both Stenosis and Aneurysm (n=31, 48±12) groups (p=0.044). The most common sites of lesions were the distal vertebral artery and posterior inferior cerebellar artery (n=43, 57%). All patients in Aneurysm Only group had their lesions in the posterior circulation (61% in Stenosis Only, 77% in Both Stenosis and Aneurysm; p=0.047). A total of 43 patients (57%) showed improvement of initial lesions on follow-up vascular images (58% in Stenosis Only vs. 22% in Aneurysm Only vs. 65% in Both Stenosis and Aneurysm; p=0.076). The proportion of patients who obtained improvements on follow-up vascular images on baseline images was lower in Aneurysm Only compared with groups with stenosis (Stenosis Only and Both Stenosis and Aneurysm) (Odds ratio 0.18, 95% CI 0.03 to 0.94; p=0.035). Conclusions: Complete or partial improvements on follow-up images are obtained in over half of the patients with acute cervicocerebral artery dissection. Patients with only aneurysm on early images showed poor imaging prognosis compared to patients with stenosis.

Efficacy of endovascular treatment and feasibility of stent-assisted coiling in the presence of severe and symptomatic vasospasm

Background and purposeIn patients with aneurysmal subarachnoid hemorrhage, deciding the optimal treatment strategy is challenging in the presence of severe and symptomatic vasospasm and the existing literature is limited. The...

Intra-arterial versus intravenous abciximab therapy for thromboembolic complications of neuroendovascular procedures: case review and meta-analysis

BackgroundAbciximab is used to treat thromboembolic complications of neuroendovascular procedures, but outcomes of treatment are not well defined.ObjectiveTo examine the angiographic and clinical outcomes based on route of abciximab administration...

E.03 Use of intra-arterial milrinone rescue therapy in patients with refractory and super refractory vasospasm after aneurysmal subarachnoid hemorrhage

Background: Vasospasm causing delayed ischemic neurologic deficit (DIND) remains a leading cause of devastating outcome after aneurysmal subarachnoid hemorrhage (aSAH). Therapy using intravenous milrinone (IVM) and intra-arterial milrinone (IAM) has been described. We report our results using IAM in patients with refractory and super refractory vasospasm (RV and SRV respectively). Methods: Retrospective single center study of all adult patients treated with IAM between 2006 and 2016 inclusively. IAM was used as part of the Montreal Neurological Hospital Protocol when the patients’ symptoms failed to respond to initial and higher IVM doses. We report their clinical outcomes. Results: IAM was used in 19 patients. The median loading dose was 8 mg and average maintenance dose was 0.78 mcg/kg/min. Angiographic improvement was seen in 15 (79%) and clinical improvement - within the first 48 hours - was seen in all patients. The median mRS was 3 at time of discharge and 1 three months later. Five patients lost follow up. Conclusions: IAM appears to be safe and effective in this small retrospective series of RV and SRV complicating aSAH. Angiographic and clinical improvements were observed. Further prospective studies are warranted to confirm these findings.

Coronary flow improvement following unsuccessful primary percutaneous coronary intervention in ST-elevation myocardial infarction with diffuse ectatic coronary artery.

In ST-elevation myocardial infarction (STEMI) patients with diffuse ectatic coronary artery, extensive thrombi inhibit achievement of final successful revascularization of Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow after primary percutaneous coronary intervention. However, clinical and angiographic outcomes of such patients are uncertain. The present study examined clinical and angiographic outcomes in STEMI incorporating giant coronary artery with diffuse ectasia. Seven hundred and forty-four STEMI patients undergoing primary percutaneous coronary intervention were surveyed retrospectively. Culprit lesions in giant coronary artery with diffuse ectasia (Ectatic group, n=39) were investigated. Percutaneous coronary intervention success rate and angiographic or clinical outcomes at 360 days were compared with those of the Non-ectatic group ( n=705). Angiographic percutaneous coronary intervention success rate was significantly lower in the Ectatic group due to lower achievement of final TIMI grade 3 flow (53.8% vs. 92.9%, p<0.0001; 53.8% vs. 93.5%, p<0.0001, respectively). In follow-up angiography, 86% of the Ectatic group showed angiographic improvement from TIMI grade 2 or less immediately after percutaneous coronary intervention to TIMI grade 3 flow at follow-up. In contrast, angiographic improvement was observed in only 25% of cases in the Non-ectatic group. All-cause 360-day mortality was significantly lower in the ectatic group (2.6% vs. 14.5%, p=0.0361, respectively). In patients with STEMI in giant coronary artery with diffuse ectasia, achievement of TIMI grade 3 flow was significantly reduced immediately after percutaneous coronary intervention. However, improvement of coronary flow up to TIMI grade 3 was not uncommon at follow-up angiogram. Patients had low mortality despite low TIMI grade 3 achievement immediately after primary percutaneous coronary intervention.