Angiography Suite Research Articles

Importance of Instant Thrombectomy to Treat Cerebral Vessel Occlusion During TAVI in Third World Country

Background: Transcatheter aortic valve implantation (TAVI) is considered to be one of the treatments for symptomatic severe aortic stenosis. This procedure has been associated with cerebrovascular events be it thromboembolic or hemorrhagic in nature that increase the periprocedural mortality and morbidity. Strokes post TAVI are mostly ischemic in origin; they can be either due to symptomatic or silent emboli. These thromboembolic events may occur during the procedure or up to 2 months after the procedure. In the acute setting, especially during the procedure, immediate intervention is crucial for better patient outcome. Mechanical thrombectomy is the best treatment modality for immediate revascularization and stroke prevention. Case description: We present a case of a patient who developed symptomatic signs of hypoperfusion during the procedure that required an urgent mechanical thrombectomy in a third world country. The patient didn’t undergo CT imaging and wasn’t transferred to the brain angiography suite; the procedure was done using the x-ray machine and in the cardiology catherization lab which lacks proper equipment to do cerebral DSA (Digital subtraction angiography). This case is the 8th to be reported in the literature where mechanical thrombectomy was done on the table during a TAVI procedure. Based on this case and the literature review, we will propose an algorithm for dealing with similar cases. Conclusion: We highlight the importance of instant thrombectomy that should be done in a patient suffering from a thromboembolic event while performing TAVI procedure. Using the same endovascular access, in the same setting in the cardiac catherization lab to assess thrombus location, even if done sub-optimally without DSA, in correlation with patient’s symptoms, without taking the patient to perform a CT scan, is life saving and guarantees quick reperfusion after clot aspiration with clinical improvement afterwards and better patient outcome.

Procedural Software Toolkit in the Armamentarium of Interventional Therapies: A Review of Additive Usefulness and Current Evidence

Interventional radiology is a fast-paced specialty that uses many advanced and emerging technological solutions. Several procedural hardware and software products are available commercially. Image-guided procedural software helps save time and effort in interventionist practice and adds precision to the intraoperative decisions made by the end user. Interventional radiologists, including interventional oncologists, have access to a wide range of commercially available procedural software that can be integrated into their workflow. However, the resources and real-world evidence related to such software are limited. Thus, we performed a detailed review of the current resources available, such as software-related publications, vendors' multimedia materials (e.g., user guides), and each software's functions and features, to compile a resource for interventional therapies. We also reviewed previous studies that have verified the use of such software in angiographic suites. Procedural software products will continue to increase in number and usage; these will likely be advanced further with deep learning, artificial intelligence, and new add-ins. Therefore, classifying procedural product software can improve our understanding of these entities. This review significantly contributes to the existing literature because it highlights the lack of studies on procedural product software.

Flat-panel dual-energy head computed tomography in the angiography suite after thrombectomy for acute stroke: A clinical feasibility study.

Management of large vessel occlusion (LVO) patients after thrombectomy is affected by the presence of intracranial hemorrhage (ICH) on post-procedure imaging. Differentiating contrast staining from hemorrhage on post-procedural imaging has been facilitated by dual-energy computed tomography (DECT), traditionally performed in dedicated computed tomography (CT) scanners with subsequent delays in treatment. We employed a novel method of DECT using the Siemens cone beam CT (DE-CBCT) in the angiography suite to evaluate for post-procedure ICH and contrast extravasation. After endovascular treatment for LVO was performed and before the patient was removed from the operating table, DE-CBCT was performed using the Siemens Q-biplane system, with two separate 20-second CBCT scans at two energy levels: 70 keV (standard) and 125 keV with tin filtration (nonstandard). Post-procedurally, patients also underwent a standard DECT using Siemens SOMATOM Force CT scanner. Two independent reviewers blindly evaluated the DE-CBCT and DECT for hemorrhage and contrast extravasation. We successfully performed intra-procedural DE-CBCT in 10 subjects with no technical failure. The images were high-quality and subjectively useful to differentiate contrast from hemorrhage. The one hemorrhage seen on standard DECT was very small and clinically silent. The interrater reliability was 100% for both contrast and hemorrhage detection. We demonstrate that intra-procedural DE-CBCT after thrombectomy is feasible and provides clinically meaningful images. There was close agreement between findings on DE-CBCT and standard DECT. Our findings suggest that DE-CBCT could be used in the future to improve stroke thrombectomy patient workflow and to more efficiently guide the postoperative management of these patients.

Computed Tomography Perfusion Imaging in Acute Ischemic Stroke: Accurate Interpretation Matters.

Computed Tomography Perfusion Imaging in Acute Ischemic Stroke: Accurate Interpretation Matters.

Abstract WMP85: Mobile Stroke Unit: Direct To Angio Or Some Stops Along The Way?

Introduction: Reducing the time from last known well to recanalization are associated with better functional outcomes and lower mortality in ischemic stroke. Recent data suggests that a “direct to angio” approach might improve the outcome of stroke patients with suspected emergent large vessel occlusion (ELVO). In this study, we aim to describe our direct-to-angiography vs those taken for additional imaging-first experience in our mobile stroke unit (MSU). Methods: Retrospective chart review from 2014 until 2022 was done. Patients with acute ischemic stroke due to ELVO arriving via MSU to our tertiary care comprehensive stroke center were included. We compared outcomes of those who went directly to the angiography suite versus those who underwent additional imaging studies first. Results: 14 patients with ELVO went directly to angio (DTA group) compared to 52 patients who underwent additional imaging (CTA group). There were no differences in age, gender, pre-morbid vascular risk factors or presenting symptoms. The DTA group had a higher median initial NIHSS and a higher interquartile range when compared to the CTA group but not significant. The DTA group received more thrombolytic therapy compared to the CTA group (p = 0.03). The DTA group had better door-to-groin times (median 39 minutes) compared to the CTA group (median 51.5 minutes) (p = 0.02). TICI 0 - 2a was more frequently seen in the DTA group (35.7%) compared to the CTA group (9.6%) (p = 0.03). Mortality was significantly higher in the DTA group compared to the CTA group (35% vs. 9%; p = 0.028) but there was no difference in functional outcomes amongst groups (mRS 0 - 2 28% vs 17%; p = 0.45). There was a non-significantly higher incidence of tandem occlusions in the DTA group (28.5%) compared to the CTA group (28.5% vs. 15%; p = 0.43). Conclusions: In our analysis, those going direct to angiography from the MSU had less successful recanalization and increased mortality. These findings could also be related to the higher rate of tandem occlusions in the DTA group. Due to head only scanning being available on MSU, additional information from in-hospital scanning may offer other information which may influence selection of patients for the procedure. Further analysis of these paradigms, particularly on MSUs, are warranted.

Image quality improvements for brain soft tissue in neuro-endovascular treatments: A novel dual-axis “butterfly” trajectory for optimized Cone-Beam CT

PurposeCone-beam computed tomography (CBCT) is useful in the diagnosis of complications after neuro-endovascular treatment. However, the image quality of conventional CBCT is inferior to that of conventional CT. To solve this problem, a dual-axis butterfly CBCT available with an angiography suite has been developed. This study aimed to evaluate the image quality of this dual-axis butterfly CBCT compared to the conventional CBCT in the same patient. MethodWe prospectively included patients who underwent scheduled neuro-endovascular treatment and performed conventional CBCT and novel dual-axis butterfly CBCT as a postoperative examination. We evaluated artifacts, brain contrast, and cortico-medullary junctions on a scoring system using a 5-point scale in which lower scores indicate better image quality. In addition, the white matter/gray matter ratio was calculated in selected brain lobe regions. ResultsForty-seven cases (94 paired images) were enrolled. The novel dual-axis butterfly CBCT had significantly fewer supratentorial and infratentorial artifacts in the artifact evaluation. Similarly, contrast and cortico-medullary junction discrimination in the cerebral hemispheres scored significantly better in the butterfly scan in all regions. The white matter/gray matter ROI ratio was significantly higher in the novel dual-axis butterfly CBCT in the frontal and occipital lobes but not in the temporal lobe. ConclusionsCompared to conventional CBCT, the novel dual-axis butterfly CBCT showed supratentorial and infratentorial artifact reduction as well as improved contrast with the brain parenchyma and cerebrospinal fluid space and white matter/gray matter discrimination ability.

The Role of Interventional Radiology and Management of an Angiography Suite in the Treatment of COVID-19 Patients: Single-Center, 2-Year Experience.

Background and Objectives: Hospital angiography suites with negative-pressure ventilation facilities are challenging to equip. During the COVID-19 pandemic, we aimed to introduce interventional radiology procedures performed on COVID-19 patients and understand management of the angiography suite without a negative-pressure ventilation facility before and after the procedures to prevent the spread of infection. Materials and Methods: Between December 2020 and November 2022, 52 COVID-19 patients underwent interventional radiology procedures in an angiography suite, where no negative-pressure ventilation facility was installed. During the procedure, all staff members wore full personal protection equipment, and after the procedure for the COVID-19-positive patient was completed, the angiography suite was disinfected and entry to the angiography suite was prohibited for 1-3 h. In this angiography suite, procedures for COVID-19 patients and non-COVID-19 patients were performed. Results: A total of 61 interventional radiology procedures were performed in 52 patients with COVID-19. Of 52 patients, 21 underwent procedures under intubation and mechanical ventilation. All procedures were performed according to the guidelines set by the Infection Control Committee of our hospital. No major or minor complications were associated with the procedures. There were no cases of infection among staff members or other non-COVID-19 patients related to procedures on COVID-19 patients. Conclusions: Interventional radiology can play an important role in solving the complications of COVID-19 and the problems caused by patients' underlying diseases. In addition, if accurate guidelines are followed, both COVID-19 and non-COVID-19 patients can undergo procedures in an angiography room without negative-pressure ventilation while preventing infection.

Direct transfer for thrombectomy in patients with large vessel occlusions on computed tomography angiography results in safe revascularization.

Endovascular mechanical thrombectomy (EVT) has become the standard of care treatment for both intravenous tissue plasminogen activator eligible and ineligible patients presenting with an acute ischemic stroke due to a large vessel occlusion (LVO) within 24 h. Due to limited access to EVT, patients typically present to a non-EVT-capable center and are transferred to a larger, EVT-capable center. Quality improvement work has focused on improving this process to shorten the time to definitive recanalization of the affected vessel. We retrospectively reviewed 98 consecutive patients who were transferred from an outside institution to our Comprehensive Stroke Center from July 2019 to September 2021. Thirty-nine of these patients had a diagnosed LVO at the transferring center on computed tomography angiography and were transferred directly to the angiography suite (DAT) whereas 59 patients were transferred to our Emergency Department for further imaging (EDT). Three of the patients in the DAT group did not undergo thrombectomy as there was no LVO identified on catheter angiography and were excluded from the study. Demographic and medical comorbidities were similar between the two groups. The DAT group had more severe strokes on presentation compared to the EDT group as measured by the National Institute of Health Stroke Severity (17.5 vs. 15, P = 0.048). Last known well (LKW) to arrival time in the angiography suite was significantly shorter in the DAT group (280 min vs. 474 min, P = 0.002). Patients in the DAT group were revascularized faster than the EDT group relative to LKW (320 min vs. 534 min, P < 0.001) while door-to-groin puncture and door-to-revascularization rates were similar. Modified Rankin score, incidence of symptomatic intracranial hemorrhage, and need for decompressive hemicraniectomy were similar between the two groups. Successful revascularization as measured by thrombolysis in cerebral infarction score occurred at a higher rate in the DAT group but was not statistical significance (97% vs. 85%, P = 0.055). DAT resulted in safe EVT compared to EDT with significant improvement in LKW to angiography suite presentation and subsequent vessel recanalization. Patients who underwent DAT experienced similar functional outcomes compared to EDT despite experiencing more severe strokes.

Lead-Dust Contamination on Radiation Protection Apparel

PurposeTo evaluate the prevalence of surface lead-dust contamination on radiation protection apparel (RPAs) in the radiology department and compare findings with those from other studies of RPA lead-dust contamination. Materials and MethodsA survey of RPAs was conducted between June and December 2021 in radiology departments at a tertiary-care university hospital. A convenience sample of RPAs located on wall-mounted racks outside the angiography suite and emergency department was surveyed. Surface lead dust on RPAs was detected using a rapid qualitative test. ResultsA total of 69 RPAs included full-length frontal lead aprons (n = 11), full-length frontal lead aprons (n = 25) with thyroid collars (n = 25), and thyroid collars alone (n = 8). Garments consisted mainly of a lead/antimony composite core with a 0.5-mm lead equivalency. One RPA failed radiologic quality inspection, and 8 garments were in poor or worn condition. The overall prevalence of surface lead-dust contamination on RPAs was 60.9% (95% CI, 49.1%–71.5%) and was significantly (P = .0035) higher on thyroid collars (78.8% [95% CI, 62.2%–89.3%]) than on lead aprons (44.4% [95% CI, 29.5%–60.4%]). ConclusionsA high prevalence of surface lead-dust contamination was detected on RPAs using a rapid qualitative test. There is currently no established safe level of lead, and these findings suggest RPAs be monitored frequently not only for physical defects limiting radiation protection but also for lead-dust contamination.

Can angiographic Flat Detector Computed Tomography blood volume measurement be used to predict final infarct size in acute ischemic stroke?

Introduction and purposeFlat detector computed tomography (FD-CT) technology is becoming more widely available in the angiography suites of comprehensive stroke centers. In patients with acute ischemic stroke (AIS), who are referred for endovascular therapy (EVT), FD-CT generates cerebral pooled blood volume (PBV) maps, which might help in predicting the final infarct area. We retrospectively analyzed pre- and post-recanalization therapy quantitative PBV measurements in both the infarcted and hypoperfused brain areas of AIS patients referred for EVT. Materials and methodsWe included AIS patients with large vessel occlusion in the anterior circulation referred for EVT from primary stroke centers to our comprehensive stroke center. The pre- and post-recanalization FD-CT regional relative PBV (rPBV) values were measured between ipsilateral lesional and contralateral non-lesional areas based on final infarct area on post EVT follow-up cross-sectional imaging. Statistical analysis was performed to identify differences in PBV values between infarcted and non-infarcted, recanalized brain areas. ResultsWe included 20 AIS patients. Mean age was 63 years (ranging from 36 to 86 years). The mean pre- EVT rPBV value was 0.57 (±0.40) for infarcted areas and 0.75 (±0.43) for hypoperfusion areas. The mean differences (Δ) between pre- and post-EVT rPBV values for infarcted and hypoperfused areas were respectively 0.69 (±0.59) and 0.69 (±0.90). We found no significant differences (p > 0.05) between pre-EVT rPBV and ΔrPBV values of infarct areas and hypoperfusion areas. ConclusionAngiographic PBV mapping is useful for the detection of cerebral perfusion deficits, especially in combination with the fill run images. However, we were not able to distinguish irreversibly infarcted tissue from potentially salvageable, hypoperfused brain tissue based on quantitative PBV measurement in AIS patients.

EE558 Cost-Effectiveness of Direct Transfer of Acute Ischemic Stroke Patients to Angiography Suite

EE558 Cost-Effectiveness of Direct Transfer of Acute Ischemic Stroke Patients to Angiography Suite

Procedural and Clinical Outcome Analysis of Monoplane versus Biplane Angiography Suites in Stroke Thrombectomies

Thrombectomy is now the standard of care in the treatment of acute ischemic stroke caused by emergent large vessel occlusion. Therefore, thrombectomy services have expanded from Comprehensive Stroke Centers (CSCs) to Thrombectomy-Capable Stroke Centers (TSCs). Stroke interventions at these sites are performed in both biplane and monoplane angiography suites. It has been hypothesized that differences in these systems may affect time to successful reperfusion, with a potentially significant effect on neurological outcomes. With an increase in TSCs, this study aims to evaluate the safety and efficacy of monoplane thrombectomy versus biplane thrombectomy. Patients who presented with isolated proximal middle cerebral artery (MCA) M1 occlusions and underwent endovascular thrombectomy from March 2015 to August 2018 at five different centers within a single health system were included. Thrombectomy was performed by the same group of experienced neurointerventionalists. The primary endpoint was functional outcome as measured by the modified Rankin scale at 90 days. Secondary endpoints included recanalization grade as measured by the Thrombolysis in Cerebral Infarction (TICI) score, time to final reperfusion and incidence of hemorrhagic conversion. A total of 197 patients were included in this study. Of them, 80.7% underwent thrombectomy on biplane systems. Time to final reperfusion was 10.2 minutes longer in the monoplane group but was not statistically significant (p=0.252). There was no significant difference in the rates of favorable reperfusion (p=0.755), hemorrhagic conversion (p=0.580), or functional outcome at 90 days (Favorable mRS 0-2, p=0.210; favorable mRS 0-3, p=0.697). Despite perceived advantages of biplane systems in reducing procedural time, our study demonstrates no significant differences between systems. This data not only supports the safety and efficacy of performing thrombectomy on monoplane systems, but also may carry implications for reducing patient transfer times and potentially increasing thrombectomy access to areas of the world where biplane suites may not be available. The next step would be a prospective randomized trial comparing both systems in different settings.

A Single-Centre Retrospective Analysis of Radial Versus Femoral Prostate Artery Embolization.

Purpose: To determine whether route of access, transradial or transfemoral, leads to any discernible differences in patient radiation or contrast medium exposure as well as procedure time in elective prostate artery embolization (PAE).Methods: This retrospective study included sixty patients in total: n = 30 in the radial PAE group, and n = 30 in the femoral PAE group. All procedures were performed in a single angiography suite between May 2018 and January 2021, using a standard kit for each type of vascular access, the same microcatheter/wire combination and embolic agent to super-selectively target and embolize one or both prostate arteries. Outcome measures included dose area product (DAP, µGym2), air kerma (mGy), fluoroscopy time (mins), procedure time (mins) and volume of contrast medium used (mL). Adverse events were also recorded.Results: The radial and femoral groups were matched for age (73.2 ± 7.5 vs 71.3 ± 10.14, P = .41) and body mass index (27.53 ± 5.08 vs 26.41 ± 3.93, P = .38).No significant difference in dose area product, air kerma, fluoroscopy time, procedure time or volume of contrast medium used was found between radial and femoral PAE. No adverse events occurred in either group.Conclusion: Radial PAE is safe and comparable to femoral PAE with respect to patient radiation exposure, contrast medium usage, and procedure duration. Radial access is a useful skill to add to the armament of the interventional radiologist in elective PAE.

Necessity of performing a routine chest radiograph following the insertion of tunnelled Hickman catheter under imaging guidance: A single centre experience.

A chest radiograph has traditionally been performed following the insertion of a tunnelled Hickman catheter to immediately exclude rare but potentially serious complications such as pneumothorax and haemothorax and confirm appropriate positioning of the catheter tip. The value of completing the routine chest radiograph has been questioned when fluoroscopic image may be easily obtained in the angiography suite for the same purpose, and the rate of iatrogenic pneumothorax remains extremely low in the Medical literature. We describe our experience of performing Hickman catheter insertion under ultrasound and fluoroscopic guidance and whether routinely performing the chest radiograph is justifiable. A single centre retrospective review was performed of patients who received a tunnelled Hickman catheter and underwent postprocedural chest radiograph in the Interventional Radiology Department during a fifteen-year period from August 2007 to April 2021. Patient demographics and complications were documented. Delayed iatrogenic pneumothorax was diagnosed in one asymptomatic patient (0.06%) on a chest radiograph out of 1735 patients, and they required chest tube insertion. Other complications included two cases of right common carotid artery puncture, one case of right internal jugular vein dissection and one case of left internal jugular perforation. Two patients required a repeat procedure within 24 h due to superior migration of the Hickman catheter on chest radiograph. Given the extremely low rate of iatrogenic pneumothorax, chest radiograph following the insertion of a tunnelled Hickman catheter under ultrasound and fluoroscopic guidance may be an unnecessary investigation unless the patient is symptomatic, or there is sufficient clinical concern.

Flat Detector CT with Cerebral Pooled Blood Volume Perfusion in the Angiography Suite: From Diagnostics to Treatment Monitoring.

C-arm flat-panel detector computed tomographic (CT) imaging in the angiography suite increasingly plays an important part during interventional neuroradiological procedures. In addition to conventional angiographic imaging of blood vessels, flat detector CT (FD CT) imaging allows simultaneous 3D visualization of parenchymal and vascular structures of the brain. Next to imaging of anatomical structures, it is also possible to perform FD CT perfusion imaging of the brain by means of cerebral blood volume (CBV) or pooled blood volume (PBV) mapping during steady state contrast administration. This enables more adequate decision making during interventional neuroradiological procedures, based on real-time insights into brain perfusion on the spot, obviating time consuming and often difficult transportation of the (anesthetized) patient to conventional cross-sectional imaging modalities. In this paper we review the literature about the nature of FD CT PBV mapping in patients and demonstrate its current use for diagnosis and treatment monitoring in interventional neuroradiology.

Stroke Neurointervention: A Novel Educational Pathway to Improve Neurology Resident Training in Neurointervention and Regional Access to Thrombectomy

Large vessel occlusions account for ≈30% of acute ischemic stroke. Mechanical thrombectomy is a highly beneficial treatment for large vessel occlusion strokes in appropriately selected patients. However, there is significant geographic variability in regional access to this important therapy, and broadening coverage by using non‐neuroscience specialties places patients at risk for suboptimal cerebrovascular care. An alternative solution is to train more neurologists to perform this procedure and consolidate expertise in vascular neurology. However, neurology residents have minimal exposure to the angiography suite and are disadvantaged in this regard when it comes to preparedness for fellowship training. We detail a novel training pathway incorporating neuroendovascular training into the adult neurology residency and an option to continue hybridized stroke–neurointervention training in a vascular neurology fellowship. Here, we present the development of the training curriculum, early trainee experience, and challenges to widespread implementation. The stroke–neurointervention training pathway was created with the intention of improving access to this important therapy by enfolding early training into neurology residency.

The eye lens dose of the interventionalist: Measurement in practice

ObjectiveEarly 2018, the new eye lens dose limit of 20 mSv per year for occupational exposure to ionising radiation was implemented in the European Union. Dutch guidelines state that monitoring is compulsory above an expected eye lens dose of 15 mSv/year. In this study we propose a method to investigate whether the eye lens dose of interventionalists would exceed 15 mSv/year and to determine if the eye lens dose can be derived from the regular personal dosimeter measurements. MethodsThe eye lens dose, Hp(3), of interventional radiologists (n = 2), cardiologists (n = 2) and vascular surgeons (n = 3) in the Máxima Medical Centre, The Netherlands, was measured during six months, using thermoluminescence dosimeters on the forehead. Simultaneously, the surface dose, Hp(0,07), and whole body dose, Hp(10), were measured using regular dosimeters outside the lead skirt at chest level. The dosimeters were simultaneously refreshed every four weeks. The eye lens dose was compared to both the body-worn dosimeter values. Measurements were performed in the angiography suite, Cath lab and hybrid OR. ResultsA clear relation was observed between the two dosimeters: Hp(3) ≈ 0,25 Hp(0,07). The extrapolated year dose for the eye lens did not exceed 15 mSv for any of the interventionalists (average 3 to 10 studies/month). ConclusionsThe eye lens dose can be monitored indirectly through the regular dosimeter at chest level. Additionally, based on the measurements we conclude that all monitored interventionalists remain below the dose limit and compulsory monitoring limit for the eye lens dose.

Factors Affecting Image Resolution in a Modern Angiographic Suite: A Phantom-Based Study

BackgroundImprovements in angiographic imaging systems technology provide options to decrease radiation exposure. The effect of these variations on image resolution is unknown. MethodsUsing an American National Standards Institution phantom, a high-contrast (line-pair) and low contrast (Gammex 151) phantoms, 5 second images were acquired using a Phillips Allure angiographic suite, using fluoroscopic capture (FC) as well as cineangiography (CA) in posterior anterior (PA) and left anterior oblique (LAO) projections as well as high and low table positions. Image resolutions were measured as ranked by three independent trained observers blinded to the purpose of the assessments. Comparative analyses were performed. Interobserver agreement was evaluated. ResultsHigh contrast image resolution was significantly lower with FC compared to CA (median [interquartile range], 1.69 [1.52–1.69] mm, vs 2.09 [1.88–2.09] mm, P < 0.001). No significant differences were observed in between PA and LAO projections as well as low and high table positions. Low contrast resolution was also lower with FC compared to CA (5 [6.5–5] vs 3 [5–3] mm, P < 0.001). No significant differences in high-contrast or low-contrast resolution were noted between PA and LAO projections, or high and low table positions. Both low and high-contrast image resolution improved with higher radiation exposure. Good interobserver agreement was noted (Fleiss-Kappa ranging from 0.69–0.74). ConclusionImage resolution was perceived to be better with CA compared to FC, although not significantly affected by beam angulation or table height. Aligning resolution needs with imaging modality and maximizing table height may improve procedural efficacy and safety.

Direct to Angiosuite Versus Conventional Imaging in Suspected Large Vessel Occlusion: A Systemic Review and Meta-Analysis.

There is growing evidence to suggest that the direct transfer to angiography suite (DTAS) approach for patients with suspected large vessel occlusion stroke potentially requiring mechanical thrombectomy shortens treatment times and improves outcomes compared with the direct transfer to conventional imaging (DTCI) model. Therefore, we conducted this meta-analysis to compare both approaches to build more concrete evidence to support this innovative treatment concept. All potentially relevant studies published in 4 electronic databases/search engines (PubMed, Web of Science, Cochrane Library, and Scopus) from inception to November 2021 were reviewed. Eligible studies were included if they enrolled ≥10 patients in both groups, were published in English, and reported baseline and procedural characteristics and outcomes. Relevant data were then extracted and analyzed. Among 4514 searched studies, 7 qualified for the analysis with 1971 patients (DTAS=675, DTCI=1296). Times from door to puncture (mean difference, -30.76 minutes [95% CI, -43.70 to -17.82]; P<0.001) as well as door-to-reperfusion (mean difference=-33.24 minutes [95% CI, -51.82 to -14.66]; P<0.001) were significantly shorter and the rates of functional independence (modified Rankin Scale score, 0-2: risk ratio [RR], 1.25 [95% CI, 1.02-1.53]; P=0.03) at 90 days were higher in the DTAS versus the DTCI approach. There was no difference across the DTAS and DTCI groups in terms of the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2B-3: RR, 1.03 [95% CI, 0.95-1.12]; P=0.42), near-complete/full reperfusion (modified Thrombolysis in Cerebral Infarction 2C-3: RR, 0.89 [95% CI, 0.74-1.08]; P=0.23), symptomatic intracranial hemorrhage (RR, 0.81 [95% CI, 0.56-1.17]; P=0.26), or fair outcomes (modified Rankin Scale score, 0-3: RR, 1.14 [95% CI, 0.88-1.47]; P=0.32) or mortality (RR, 0.98 [95% CI, 0.67-1.44]; P=0.93) at 90 days. Subgroup analysis showed no significant difference in 90-day functional independence across approaches in transfer patients (RR, 1.20 [95% CI, 0.96-1.51]; P=0.11). Our meta-analysis showed that the DTAS approach seems to be associated with improved time metrics and functional outcomes with comparable safety to the DTCI approach. Ongoing multicenter randomized clinical trials will hopefully provide more definite data about this promising approach.

The Hybrid Operative Suite with Intraoperative Biplane Rotational Angiography in Pediatric Cerebrovascular Neurosurgery: Utility and Lessons Learned

Introduction: The benefits of performing open and endovascular procedures in a hybrid neuroangiography surgical suite include confirmation of treatment results and reduction in number of procedures, leading to improved efficiency of care. Combined procedural suites are infrequently used in pediatric facilities due to technical and logistical limitations. We report the safety, utility, and lessons learned from a single-institution experience using a hybrid suite equipped with biplane rotational digital subtraction angiography and pan-surgical capabilities. Methods: We conducted a retrospective review of consecutive cases performed at our institution that utilized the hybrid neuroangiography surgical suite from February 2020 to August 2021. Demographics, surgical metrics, and imaging results were collected from the electronic medical record. Outcomes, interventions, and nuances for optimizing preoperative/intraoperative setup and postoperative care were presented. Results: Eighteen procedures were performed in 17 patients (mean age 13.4 years, range 6–19). Cases included 14 arteriovenous malformations (AVM; 85.7% ruptured), one dural arteriovenous fistula, one mycotic aneurysm, and one hemangioblastoma. The average operative time was 416 min (range 321–745). There were no intraoperative or postoperative complications. All patients were alive at follow-up (range 0.1–14.7 months). Five patients had anticipated postoperative deficits arising from their hemorrhage, and 12 returned to baseline neurological status. Four illustrative cases demonstrating specific, unique applications of the hybrid angiography suite are presented. Conclusion: The hybrid neuroangiography surgical suite is a safe option for pediatric cerebrovascular pathologies requiring combined surgical and endovascular intervention. Hybrid cases can be completed within the same anesthesia session and reduce the need for return to the operating room for resection or surveillance angiography. High-quality intraoperative angiography enables diagnostic confirmation under a single procedure, mitigating risk of morbidity and accelerating recovery. Effective multidisciplinary planning enables preoperative angiograms to be completed to inform the operative plan immediately prior to definitive resection.