Emergency Endovascular Treatment Research Articles

Abstract 2427: Significance of Susceptibility Vessel Sign on T2 Star Weighted-images to Predict Clinical Outcome following Emergency Endovascular Treatment in Patients with Probable Acute Embolic Basilar Artery Occlusion

Purpose The purpose of our retrospective study is to investigate whether or not susceptibility vessel sign of the basilar artery (SVS-BA) on T2*-weighted gradient echo images at 1.5T can predict clinical outcome after emergency endovascular treatment (EET) in patients where MRA suggests the embolic acute BA occlusion. Materials and Methods Included for retrospective analysis were patients as follows, (1) study period was from November 2005 to December 2010, (2) who were admitted to our institution within 8 hours from stroke onset, (3) who underwent emergency MR imaging including DWI, T2*WI, MRA at 1.5T and symptomatic and embolic acute BAO was diagnosed by MRA, (4) whose NIHSS score on admission was 10 or more, and (5) who underwent EET. Excluded were patients (1) in whom DWIs showed extensive high signal intensity area in pons or cerebelli, (2) who had contraindications for EET. They were divided into two groups according to presence (group P) or absence (group A) of SVS-BA on T2*WI. The relationships between the presence of BA-SVS and patients’ baseline characteristics on admission (age, gender), onset to admission time (OTA time), onset to treatment time (OTT time), NIHSS on admission (NIHadm), NIHSS on the 7th day (NIH7th), modified Rankin Scale at 3 months (3M-mRS) and estimated lengths of BAO on emergency MRA (eMRA) were investigated. Estimated lengths of BAO were graded according to eMRA as follows: grade 4, no occlusion; grade 3, occluded distal AICA; grade 2, occluded distal union; grade 1: not visualized. TIMI grades 2 and 3 were defined as successful recanalization. Results During the study periods, 17 patients were included for analysis. Successful recanalization was achieved in 11 patients (65%). In P (n=8) and A (n=9) groups, there were no significant differences statistically in age (mean; 73.6±15.2 and 68.1±14.0 years), man (%) (88 and 89), OTA time (median; 0.8 and 1.7 hrs), OTT time (median; 4.2 and 3.5 hrs), and NIHadm (median; 27 and 16). There were significant differences between two groups in BAO grade (median; 1.5 and 3), successful recanalization rate (%) (38 and 89), NIH7th (median; 35 and 8), 3M-mRS (median; 5.5 and 3) (p<0.05), respectively. Conclusion Clinical outcome following emergency endovascular treatment for probable acute embolic basilar artery occlusion was better in patients without SVS-BA on T2*WI than with SVS-BA. The SVS-BA on T2*WI seems to be a significant predictor for achieving less recanalization immediately after EET.

Abstract 3274: Early Symptom Onset to Arterial Puncture Time in the Endovascular Management of Acute Ischemic Stroke Predicts Successful Revascularization

Background: As is seen in the early door-to-needle times of intravenous thrombolysis in the treatment of acute ischemic stroke (AIS), prior endovascular management trials have demonstrated early revascularization can lead to improved outcomes. We aimed to study the relationship of the time from acute stroke onset to the time of arterial groin puncture (OTP) as a possible predictor of successful revascularization. Methods: We retrospectively analyzed 149 patients who presented to our hospital with AIS and underwent emergent endovascular treatment from January 1, 2008 to March 31, 2011. Charts were reviewed for baseline characteristics, OTP times, and endovascular therapies employed. Primary outcomes included successful revascularization (TIMI 2 to 3 flow), improvement of baseline NIHSS ≥ 4, symptomatic ICH (increase of NIHSS ≥ 4), in-hospital mortality, and mRS two or less at discharge. We excluded patients with OTP times greater than eight hours to ensure consistency with approved usage of mechanical thrombectomy devices. Independent samples T-tests were performed to determine relationships of OTP with our primary outcomes. Results: Of the 149 patients who underwent endovascular therapy, 120 had OTP times less than eight hours. Of these 120, 44% were male, median age was 73 years (range 17, 93), median baseline NIHSS was 18 (range 5, 28), 53% received intravenous tissue plasminogen activator (tPA), 69% received intra-arterial tPA, and mechanical thrombectomy was performed in 69%. Internal carotid artery occlusions were seen in 32% of patients, 50% had M1 segment occlusions, and only five patients had posterior circulation occlusions. Successful revascularization was achieved in 70% of interventions, 10% of patients had mRS ≤ 2 at discharge, symptomatic hemorrhage was 18%, and in-hospital mortality was 24%. Patients with TIMI 2 to 3 flow had significantly shorter mean OTP times (3.9 vs 4.5 hours; p=0.024). No significant associations of mean OTP times were found with symptomatic hemorrhage rate (4.4 vs 4.0; p=0.628), in-hospital mortality (4.0 vs 4.0; p=0.677), improvement in NIHSS (3.9 vs 4.2; p=0.283), or a mRS ≤ 2 at discharge (3.7 vs 4.1; p=0.185). Conclusions: The recanalization rate in our study is comparable to prior endovascular trials. Patients with OTP times less than 3.9 hours were more likely to result in successful revascularization. Onset to groin puncture did not predict in-hospital mortality, symptomatic hemorrhage, or condition at discharge in our study. Further study is needed to determine if advanced perfusion imaging prior to intervention may impact treatment time and ultimately clinical outcome.

Abstract 3600: A Critical Analysis of Intra-arterial Thrombolytic Doses in Acute Ischemic Stroke Patients.

Background: Intra-arterial (IA) recombinant tissue plasminogen activator (IV rt-PA, Alteplase), Tenecteplase, and Retplase are currently used in patients with acute ischemic stroke, the relationship between IA dose and hemorrhage rates, clinical outcomes and radiographic outcomes have not been rigorously studied. Objective: We evaluated the safety and recanalization efficacy associated with various doses of intra-arterial thrombolytics for treating acute ischemic stroke patients. Methods: Consecutive patients with acute ischemic stroke who underwent emergent endovascular treatment over seven years from our prospectively maintained database were included. Univariate and multivariate analyses were performed to determine the dose response relationship between thrombolytic doses and outcomes. For standardization we used a conversion of newer thrombolytics to establish a standard dosage throughout cases (10mg alteplase = 2 Units of Reteplase = 6.3 Units of Tenectaplase). Patient characteristics and outcomes were analyzed including age, weight, risk factors, use of intravenous rt-PA,and use of additional mechanical thrombolysis. The rates of intracerebral hemorrhage (ICH) and favorable clinical outcomes (discharge modified Rankin score (mRS) = 0-2) were analyzed with various doses after adjusting for potential confounders. Results: There were 290 patients [male 52% (n=150)] who received endovascular treatment for acute ischemic stroke, of those 210 (72%) were treated with IA rt-PA or equivalent thrombolytics with doses up to 69 mg of alteplase. There were 115 patients (40%) [men 46% (n=53)] who received both IV and IA therapy. Mean±SD IA tPA dose was 10±9 mg (range: 1.5-69mg) and total IA+IV tPA dose 85±21 mg (range: 43-149mg). Neither the dose of IA tPA nor total tPA dose (IV+IA) was associated with favorable outcomes or ICH (p=NS). Mean IA tPA dose was no different between the patients with and without ICH [9.9 versus 9.8, p=0.4]. Adjusting for age, admission NIHSS score, and IA tPA/equavalent dose, the use of combined mechanical and thrombolytic IA therapy was associated with higher ICH rate (OR=4, p=0.004) but not with favorable outcomes (p=0.2) compared to thrombolytic therapy alone. Multivariate analysis showed administration of IV rt-PA significantly improved favorable outcomes compared to IA therapy alone (OR=1.8, p=0.04) with no increased risk of hemorrhage (p=NS). Conclusion: Our study demonstrates that IA rt-PA or equivalent thromboytics in doses up to 69 mg are safe without any evidence of dose related adverse events even in those patients who had received IV rt-PA prior to procedure presumably due to the short-half life of rt-PA.

Successful emergency endovascular treatment of juxtarenal and infrarental mycotic aortic aneurysms in patients with small diameter aortae using Cook(®) Zenith ESLE Stentgrafts.

Endovascular repair of mycotic aneurysm is an alternative to open repair if the patho-anatomy is suitable. The aortic size above and below the mycotic aneurysm may be small. A retrospective review was made of prospectively collected departmental computerised database. Three oriental patients with juxta- and infra-renal mycotic aortic aneurysms with a small aortic diameter of 17 mm to 18 mm underwent successful emergency endovascular treatment using Cook(®) Zenith ESLE stentgrafts. These are ancillary devices aimed at iliac extensions usually. This is to our knowledge the first case series of Cook(®) Zenith ESLE iliac component endografts for the treatment of aortic mycotic aneurysms with small aortae, and short- and mid-term results are encouraging.

Emergent endovascular treatment of a bleeding recurrent aortoenteric fistula as a “bridge” to definitive surgical repair

We report the case of a 59-year-old man who developed a recurrent aortoenteric fistula (AEF) following previous aorto-bifemoral bypass grafting and subsequent AEF open repair with aorto-bifemoral graft excision and extra-anatomic reconstruction. The patient was treated emergently by means of endovascular plug deployment via a left brachial approach into the infrarenal aortic stump, obtaining recovery of hemodynamic stability. Five days later, he underwent elective relaparotomy, aortic plug removal, infrarenal aortic ligature, and duodenal repair. Endovascular strategies to rapidly stop bleeding associated with recurrent AEF may serve as a "bridge" to definitive open repair, as in the case discussed herein. Even if rare, recurrent AEF following previous prosthetic aortic graft excision and extra-anatomic revascularization represents a dreadful event. Since surgical treatment is technically demanding and time consuming in emergent settings, we present an "unconventional" endovascular option to obtain quick cessation of aortic bleeding.

Endovascular Treatment in Emergency Setting of Acute Arterial Injuries After Orthopedic Surgery

To assess the feasibility and effectiveness of emergency endovascular treatment of acute arterial injuries after orthopedic surgery. Fifteen patients (mean age 68.3years) with acute arterial injuries after orthopedic surgery were observed, in particular, 5 patients with pseudoaneurysm, 9 patients with active bleeding, and 1 patient with arterial dissection. Transarterial embolization (TAE) and positioning of covered and noncovered stents were the treatments performed. Follow-up after stent implantation (mean 36months) was performed with color Doppler US (CDU) at 1, 3, 6, and 12months and yearly thereafter. Plain X-ray was performed to evidence dislodgment or fracture of the graft. A minimum of 12months' follow-up is available after TAE. Immediate technical success was obtained in all cases. No major complications occurred. Overall clinical success rate was 100%. During mean follow-up, stent-graft occlusions did not occurred. No recurrence and/or consequence of TAE was registered during a minimum follow-up of 12months. Percutaneous treatment is a feasible and safe tool for treating arterial injuries because it can provide fast and definitive resolution of the damage. This low-invasiveness approach can be proposed as first-line treatment in patients with acute injuries after orthopedic surgery.

Percutaneous Balloon-Expandable Stent Graft Repair of a Ruptured Iliac Aneurysm

Elective stent graft repair of iliac aneurysm is successful and safe. There are, however, few published data on stent grafting unstable patients with acute iliac aneurysm rupture. Iliac diameter mismatch can also present a challenge to emergency endovascular treatment. We report the treatment of an unstable patient with iliac aneurysm rupture and diameter mismatch using a percutaneous balloon-expandable polytetrafluoroethylene (PTFE) stent graft. Outcomes were satisfactory up to 12-month follow-up. Treatment of iliac aneurysm rupture using a balloon-expandable stent graft can be successful in selected patients. A percutaneous approach and targeted stent graft postdilatation enable prompt repair in the presence of diameter mismatch, facilitating emergency therapy.

A Multicenter Analysis of “Time to Microcatheter” for Endovascular Therapy in Acute Ischemic Stroke

At present, no time recommendation for initiation of endovascular treatment in acute ischemic stroke is available. A multicenter analysis was designed to identify variables that prolong "time to microcatheter," defined as the time interval from computed tomographic scan to microcatheter placement in the cerebral circulation. Consecutive acute ischemic stroke patients from 3 academic stroke centers were included. Analysis of covariance was used to evaluate different variables that prolong "time to microcatheter." Ninety-one patients underwent emergent endovascular treatment for acute ischemic stroke. Mean "time to microcatheter" was 174±60 minutes. No significant time difference was found in patients who were intubated, presented at night or weekends, were administered intravenous recombinant tissue plasminogen activator, or underwent additional imaging prior to endovascular treatment. "Time to microcatheter" was significantly longer in nonlevel I trauma centers and in patients with National Institutes of Health Stroke Scale Score of 10 to 19. Wide variability of "time to microcatheter" among institutions highlights the need for standardized time goals.

Combined Retrograde Stent-Graft Placement and Surgical Repair for a Stanford Type A Aortic Dissection

To report a case of retrograde acute Stanford type A aortic dissection treated without hypothermic circulatory arrest. A 55-year-old man presented with a retrograde acute type A aortic dissection with an entry tear 30 mm below the left subclavian artery. A concurrent emergent endovascular and surgical treatment was performed, excluding the entry tear with retrograde delivery of a stent-graft and replacing the ascending aorta with a Dacron tube without circulatory arrest. Avoiding hypothermic circulatory arrest was the main advantage of this hybrid therapeutic choice. This combined technique may be of interest in acute retrograde type A dissections that present complications such as impending rupture or visceral malperfusion. A close collaboration between endovascular specialists and cardiac surgeons is essential for such a hybrid strategy.

Emergency Endovascular Treatment of Popliteal Aneurysms

Popliteal artery aneurysm (PAA), despite being rare, is the most common peripheral aneurysm. It can present as acute thrombosis and occlusion of the aneurysmal segment, and distal embolization, causing either chronic or acute limb ischemia. It has traditionally been treated with open surgical reconstruction. Endovascular repair of PAAs has recently been applied electively with a favourable early and mid-term outcome; however there is a lack of reports on the endovascular treatment of PAAs presenting with acute complications. This report describes the treatment of a thrombosed PAA in a 58 year old male using an endovascular stent-graft and also provides a systematic review of the literature on the emergency endovascular treatment of PAAs.

Mycotic aneurysm of the thoracic aorta caused by extended-spectrum beta-lactamase-producing Escherichia coli

We report a case of successful treatment of a mycotic aneurysm of the thoracic aorta. A 65-year-old man with a dissecting aneurysm presented with urinary tract infection. He had a history of severe liver cirrhosis. Two weeks after admission, he had a high-grade fever and enhanced computed tomography (CT) demonstrated acute expansion of the distal aortic arch aneurysm. Because of the acute aneurysm expansion and elevated inflammatory response, we suspected a mycotic aortic aneurysm with possible impending rupture. Since conventional open chest surgery was considered to carry a high operative risk, the patient was managed with a combination of emergency endovascular treatment and antibiotic chemotherapy. Extended-spectrum beta-lactamase-producing Escherichia coli were identified from blood culture before treatment. After strict antibiotic therapy, the postoperative course was uneventful and the patient remained well 12 months later.

General Is Better Than Local Anesthesia During Endovascular Procedures

Carlos A. Molina MD, PhD Magdy H. Selim MD, PhD Section Editors: The Case: A patient presents with aphasia and right-sided weakness within 5 hours of onset, and occlusion of the proximal portion of the left middle cerebral artery. Emergent endovascular treatment is indicated. The Questions: (1) Should intubation and artificial ventilation be performed before the procedure? (2) Is local anesthesia safe enough to be used, instead of general anesthesia, during the procedure? The Controversy: General anesthesia is preferable to local anesthesia during cerebral endovascular procedures. There is no doubt that general anesthesia is needed during neuroendovascular interventions such as aneurysm coiling, intracranial stenting, balloon angioplasty (percutaneous transluminal angioplasty), or embolization of arteriovenous malformations. Increasingly, advances in intracranial catheter techniques for endovascular treatment of stroke warrant general anesthesia as well. These microsurgical interventions require the navigation and proper placement of microcatheters, microwires, and devices in cerebral arteries as small as 1 mm in diameter. At the beginning of all these interventions, it is essential to acquire a road map. The angiogram is superimposed on the subsequent fluoroscopic live images to allow proper navigation of microcatheters into the intended vessels. However, patient …

Emergency endovascular treatment of early spontaneous nonaneurysmal popliteal artery rupture in a patient with Salmonella bacteremia

Rupture of a nonaneurysmal popliteal artery and subsequent pseudoaneurysm formation is an exceedingly rare event after bacteremia caused by Salmonella spp. Only a few cases have been reported in the literature. Moreover, spontaneous popliteal artery rupture resulting from this pathology, to our knowledge, has not been reported. We describe an early spontaneous rupture of the popliteal artery complicated by acute compartment syndrome in a 67-year-old man who had recently experienced fever, chills, and diarrheal syndrome and had sustained episodes of bacteremia infection, with isolation of S enteritidis. Immediate endovascular sealing of the bleeding site was achieved with a covered stent, and his recovery was uneventful. The long-term durability of endovascular repair in this type of pathology remains to be determined, however.

Two cases of emergent endovascular treatment for carotid blowout syndrome after free flap reconstruction for neck cancer

Carotid blowout is a devastating complication in patients with head and neck malignancy, and is associated with high morbidity and mortality. For patients with bleeding originating in the internal or common carotid artery, treatment options are limited. These include the endovascular remodelling strategies using a stent or embolization of the aneurysm with coils. We describe two cases of pseudoaneurysmal rupture in the common carotid artery with massive bleeding in patients with head and neck malignancies and a history of long-term radiation treatment. They underwent immediate coil embolization and wall stent deployment and, which resulted in the successful control of bleeding. Although these endovascular treatments often result in recurrent carotid blowout syndrome, they can be useful and effective in treating emergent carotid rupture in patients for whom balloon occlusion test is contraindicated.

Short- and long-term outcomes after endovascular management of ruptured descending thoracic aorta

Objective: Surgical management of acute, ruptured thoracic aorta is associated with significant morbidity and mortality. This study examined the efficacy and safety of emergency endovascular treatment of aortic rupture.

A Case of the Zone III Penetrating Neck Injury with Internal Carotid Artery Laceration Treated by an Urgent Endovascular Stent Technique

Penetrating neck injuries are potentially dangerous and require emergent management because of vital structures in the neck. A 35-year-old woman was transferred to the hospital with massive bleeding in her mouth and lacerations of her neck after the stab injuries. Contrast-enhanced computed tomography (CT) and angiography revealed a leakage at the pharyngeal portion of the right internal carotid artery. Emergent endovascular treatment was undertaken by using the stent technique. The leakage was completely occluded immediately after the procedure. There was no complication. The stent technique was safe and effective for the treatment of zone III carotid artery stab injuries. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:236-40 Key WordsZZWounds·Penetrating·Carotid artery injuries·Angiography·Stents.

Outcome of emergency endovascular treatment of large internal iliac artery aneurysms with guidewires

Purpose Guidewires have been reported as a useful occlusion material for large aneurysms of different locations with good short-term results. In this study we retrospectively evaluate long-term results of emergency embolization technique with guidewires in symptomatic internal iliac artery aneurysm (IIAA) impending rupture. Patients and methods In four patients presented with acute abdominal pain, multidetector computed tomography revealed unstable, 7–14 cm large, IIAAs. Two patients were treated with coil embolization of distal branches followed by occlusion of aneurysmal sac with guidewires. In two patients embolization of aneurysmal sac alone was performed. Results In three patients complete or near complete occlusion of the aneurysmal sac was achieved and abdominal pain ceased within hours. Two patients treated with embolization of distal iliac artery branches and aneurysmal sac developed claudication that lasted up to 1 year. Their aneurysms remained thrombosed and they were without symptoms until they died 31 and 56 months later of causes unrelated to IIAA. Two patients treated with embolization of the aneurysm alone were free of ischemic symptoms. Because of incomplete embolization of the sac in one patient open surgery treatment in a non-emergency setting was performed. Complete filling of aneurysmal sac was achieved in other patient but 2 years later his aneurysm re-opened and required open surgery treatment. Conclusion Embolization of aneurysmal sac of large IIAA with guidewires may be effective for immediate treatment of impending rupture. Long-term results were better when embolization of the aneurysmal sac was combined with embolization of distal IIA branches.

Emergency Endovascular Treatment of Sac Rupture for Type IIIa Endoleak in Thoracic Aortic Aneurysm Previously Excluded with Endovascular Repair

Elective endovascular treatment of thoracic aortic pathology has been applied in a variety of conditions. The complications of thoracic aortic stenting are also well recognized. Endoleak after endovascular repair of thoracic aortic aneurysms is the most frequent complication; among them, type III is the least frequent. Endovascular treatment of type III endoleak is generally performed under elective conditions; less frequently, in emergency. We report a successful emergency endovascular management of post-thoracic endovascular repair for thoracic aortic aneurysm rupture due to type IIIa endoleak.

Emergency endovascular treatment of the traumatic subdiaphragmatic abdominal aorta rupture by firearm

Emergency endovascular treatment of the traumatic subdiaphragmatic abdominal aorta rupture by firearm

Emergency Endovascular Treatment of a Traumatic Sub-Diaphragmatic Abdominal Aorta Rupture Caused by a Firearm

We report a case of a sub-diaphragmatic abdominal aorta rupture in a 50-year-old man, due to a shot at point-blank range with a firearm. Following a diagnostic thoraco-abdominal computed tomography (CT) scan, he was immediately transferred to the operating room where a Talent aortic cuff was implanted. There were no postoperative neurological sequelae or complications. The endoprosthesis was in the correct position with no evidence of migration, fracture or endoleak even after 9 months of follow-up.