Endovascular Management Research Articles

A Multicenter Retrospective Study Evaluating Distal Radial Access vs. Conventional Transradial or Transvenous Access for Endovascular Treatment of Malfunctioning Dialysis Fistulas

Background: This study aims to evaluate the feasibility, efficacy, and safety of distal transradial access (dRA) for the endovascular management of malfunctioning dialysis fistulas. This study also compares dRA with conventional access techniques, such as proximal radial and transvenous access, focusing on technical success, clinical outcomes, and vascular access site complications (VASCs). Methods: A retrospective multicenter study was conducted across four hospitals, including 292 patients treated between January 2019 and June 2024. Of these, 57 patients underwent dRA, and 235 received proximal radial or transvenous access. Key outcomes included technical success (successful completion of the procedure), clinical success (restoration of functional dialysis access), and complication rates. Data were collected on procedure times and complication profiles. Results: Technical success was achieved in 96.5% of patients undergoing dRA, compared to 98.3% in those receiving conventional access (p = 0.388). Clinical success was similar between groups (96.5% vs. 97%, p = 0.835). The overall complication rate was 10.5% for dRA and 8.5% for conventional access (p = 0.632). Cannulation time was longer for dRA (109.1 vs. 91.9 s, p < 0.001), but total procedure duration was comparable between the groups. No major complications were observed in either cohort, and improved post-procedure access flow rates were recorded in all patients. Conclusions: Distal transradial access is a feasible and effective approach for the endovascular management of malfunctioning dialysis fistulas, with outcomes comparable to conventional access techniques. It provides a safe alternative, particularly for patients with complex fistulas, while maintaining a low complication profile.

A Concise Review of Marfan Syndrome with a Congenital Cardiac Surgery Focus.

Marfan syndrome is named after Antoine Marfan, who described a 5-year-old child with congenital elongation of the digits and other skeletal abnormalities in 1896. While Marfan syndrome is a systemic connective tissue disorder predominantly involving the skeletal, cardiovascular, and ocular systems, the cardiovascular system presents the most life-threatening complications. Most cardiovascular pathologies surround the left ventricular outflow tract and aorta, with aortic dissection requiring emergent surgical management to the progression of mitral regurgitation requiring elective surgery. Intensive care management, along with a tailored approach to the surgical management of a patient with Marfan syndrome, is critical to their survival. Current surgical operations for patients include aortic root surgery, valve-sparing root replacements, aortic root replacements with conduits, and mitral valve repairs. Further research is necessary to determine the molecular, endovascular, pharmaceutical, and surgical management of Marfan syndrome. This review attempts to concisely discuss the diagnosis, complications, and medical and intensive care management of Marfan syndrome while further divulging on the surgical management of those with this disease process.

Successful Pedal Bypass in a Patient With Pseudoxanthoma Elasticum.

Pseudoxanthoma elasticum (PXE) is a rare metabolic disease, causing calcification in the arterial media layer and further peripheral artery disease (PAD). A high rate of failure has been reported after endovascular and open surgical management of PAD among patients with PXE. Critical limb ischemia (CLI) rarely develops in PXE, and there are only few reports of its treatment. We present a case report of a 57year-old female diagnosed with pseudoxanthoma elasticum (PXE). She presented with critical limb ischemia (CLI) and was successfully treated with pedal bypass using the great saphenous vein. Despite obtaining suboptimal outcomes through the initial approach of percutaneous transluminal angioplasty to treat critical limb ischemia, the subsequent bypass operation proved to be a success. At the first follow-up appointment at 1month, the patient was asymptomatic and the ulceration had almost healed. The patient underwent an ultrasound examination at 3, 6, 12, and 24months after discharge, and the surveillance was uncomplicated. With a clear indication for surgery, limb-threatening ischemia can be successfully treated with distal bypass, if necessary, in patients with PXE similarly to atherosclerotic PADs. Appropriate diagnostic and surveillance imaging and the utilization of a multidisciplinary team are key components for effective management of PAD in patients with PXE.

A New Bailout Maneuver to Manage Type IIIa Endoleak Due to Displaced Renal Bridging Stent Graft in Narrow Aorta.

To present endovascular management of an intraoperative type IIIc endoleak (EL) in a patient with migration of the right renal artery (RRA) bridging stent graft (BSG) during branched aortic aneurysm repair. The technique is demonstrated in an 80-year-old woman who underwent branched endograft repair of a symptomatic 6-cm type II TAAA. The t-Branch thoracoabdominal stent graft was positioned without difficulty. A "partial graft deployment" was performed, with the distal portion of the device remaining inside the delivery system and the right renal and superior mesenteric arteries were stented. When the constraining wires were removed, the RRA BSG migration from the branch was displayed, due to endograft twisting resulting in a horizontal rotation of the t-Branch. The RRA BSG remained oriented upward with the proximal edge positioned above the distal edge of the directional branch, making cannulation very difficult. This bailout technique uses a balloon placed at the level of the RRA BSG through the celiac artery (CA) directional branch; keeping the balloon inflated and in thrust, the edge of the BSG has moved downward making it possible to engage it and relining through the RRA directional branch. This paper describes an endovascular bailout technique for relining a displaced bridging stent graft, oriented upwards with the proximal edge positioned above the distal edge of the directional branch. This sophisticated technique adds to the spectrum of bailout techniques that can be applied in cases of type IIIa EL with migration and complete separation of BSG.

Postdissection Abdominal Aorto-Iliac Aneurysm Open Repair: A Surgical Technique Description and Systematic Review of the Literature

BackgroundPost-dissection abdominal aortic aneurysms (pDAAA) may develop in up to 7% of patients affected by aortic dissection. However, there is no consensus on the optimal management. Different endovascular and open surgical techniques have been reported. This case-series describes the open surgical technique employed at a tertiary vascular surgery center to manage this complex pathology to allow future treatment of the visceral aorta if needed. A systematic review of the relevant literature on surgical and endovascular management of pDAAA was conducted. MethodConsecutive patients surgically treated at a single center for pDAAA metachronous to a Stanford type A or type B aortic dissection from January 2018 to March 2023 were retrospectively retrieved. The surgical technique we employed entails the use of large-diameter bifurcated grafts (≥ 9 mm branches) with longer main body, fenestration of the septum at renal arteries ostia and landing on a common femoral artery in case of small caliber iliac arteries (< 8 mm) to provide a suitable landing zone and access route for future endovascular thoracoabdominal repair in case of subsequent aneurysmal degeneration. The primary outcome was 30-day mortality. Secondary outcomes were major complications, late mortality, aortic-related mortality, and aortic-related reinterventions. Then, a systematic review of the literature until March 2023 was conducted. ResultsFive patients were included, all males with a mean age of 61 years. 30-day mortality was 0. One patient suffered from post-operative acute kidney injury and acute distress respiratory syndrome, and another one underwent repeat laparotomy for abdominal seroma. The mean follow-up was 44 months with no aortic-related reinterventions to date. One patient died from non-aortic-related causes 9 months after surgery. ConclusionsOpen repair of pDAAA appears to be an effective treatment in selected patients, with low mortality rates, and technical choices should consider future endovascular treatment of the thoracoabdominal aorta.

A Dedicated Algorithm for Endovascular Approach as a First-Line Treatment Option for Visceral Artery Aneurysms

Few data are reported in literature about visceral artery aneurysms (VAAs) management. The aim of the present study was to analyze VAAs management in a single institution, with a dedicated algorithm for endovascular approach as the first line treatment. A single-center retrospective cohort study was performed. Patients with a VAA submitted to either endovascular repair or open surgery from 2016 to 2023 were included. A dedicated algorithm was used to evaluate the endovascular approach feasibility assessing on the preoperative computed tomography angiography the following parameters: (a) the tortuosity of the involved artery (<150°), (b) the healthy arterial diameter (>4mm), (c) the VAA proximity to the hilum and/or the presence of a bifurcation of the aneurysmatic artery, and (d) the circumferential calcium presence. An endovascular approach was chosen if (a) and (b) criteria were satisfied without (c) and (d) ones. Otherwise, it was deemed a challenging anatomy, and an open surgical treatment was considered. In the absence of (a) and/or (b) criteria open surgery was the preferred option. Thirty-one asymptomatic aneurysms (28 patients) were treated electively. The most frequent VAA location was the splenic artery (18 cases; 58%), followed by the renal arteries (6 cases; 19%), the common hepatic artery (5 cases; 16%), the gastroepiploic artery (1 case, 3.2%) and the pancreatoduodenal artery (1 case; 3%). Twenty-two aneurysms (71%) were initially treated by an endovascular approach (stent-graft deployment and/or transcatheter embolization) with 3 (13%) of them needing a surgical conversion. Nine aneurysms (29%) were submitted directly to a surgical treatment (aneurysm resection with or without interposition bypass) with no peri-operative and long-term complications. Technical success was 90.3%. Endovascular management as a first line approach is safe and effective in most cases. A preoperative dedicated algorithm is useful to identify suitable cases. Open surgery can be considered an alternative option in specific challenging anatomical situations or in case of endovascular failure.

Endovascular Management of Thrombosed Cavoportal Anastomosis After Liver Transplantation Using Catheter Directed Thrombolysis and Stent Placement: A Case Report

Cavoportal hemitransposition (CPHT) is a rarely performed treatment technique in liver transplantation in cases of extensive splanchnic thrombosis, in which the inferior vena cava of the recipient is used to perfuse the portal vein of the allograft. A case of a 65-year-old liver transplantation patient with an acutely thrombosed cavoportal anastomosis is presented. After unsuccessful medical treatment, recanalization was obtained with transfemoral catheter directed thrombolysis, angioplasty and stent placement. Although this type of treatment has been extensively documented for the management of portal anastomotic problems after orthotopic liver transplantation, data on its application in modified transplantation techniques including CPHT are rare. This technique provides a minimally invasive treatment option in CPHT patients with cavoportal anastomotic problems, who might otherwise require complex surgical repair or retransplantation.

Feasibility and outcome of endovascular management of atherosclerotic chronic total occlusion of the popliteal artery.

Feasibility and outcome of endovascular management of atherosclerotic chronic total occlusion of the popliteal artery.

Advancements in Endovascular Treatment of Extracranial Carotid Artery Aneurysms

Traditionally, extracranial carotid artery aneurysms or pseudoaneurysms (ECCAs) have been managed through open surgical repair. Recent literature highlights the increasing success of endovascular techniques in treating ECCAs. Our study explores our center's experience with endovascular management of ECCAs, including the innovative use of Transcarotid Artery Revascularization (TCAR) at a tertiary care center. We performed a retrospective analysis of patients with ECCAs who underwent endovascular intervention at a single institution. We examined our database from the period of 2010 to 2024. Our treatment modalities have expanded to include covered stenting, stent-assisted coil embolization, braided stents, overlapping closed-cell stents, and most recently Transcarotid Artery Revascularization (TCAR). There were 29 extracranial carotid artery aneurysms in 27 patients treated with various endovascular modalities. The average age was 67.6 years, with 17 (63.0%) males and 10 (37.0%) females. 8 (29.6%) patients had prior ipsilateral carotid intervention. 9 (31.0%) aneurysms were symptomatic. The most common etiology was idiopathic, with 16 (55.2%) aneurysms being spontaneous. Treatment modalities included: 2 (6.9%) treated with covered stents, 2 (6.9%) with stent-assisted embolization, 3 (10.3%) with flow-diverting braided stents, 3 (10.3%) with embolization or ligation alone, 17 (58.6%) with overlapping bare metal stents via femoral or radial access, and 2 (6.9%) with overlapping bare metal stents via TCAR. Technical success was achieved in all patients. The mean follow-up duration was 236 days (range: 2 to 3039 days). No perioperative or post-operative complications occurred, including no neurological deficits or embolic events. All patients were discharged on post-operative day 1 or 2. All 29 (100%) stents maintained vessel patency on follow-up imaging, and exclusion of ECCAs was confirmed on post-procedure surveillance imaging. Our study highlights that endovascular therapy is effective in managing ECCAs, with high patency rates and a favorable procedural safety profile.

Interventions in Budd-Chiari syndrome: an updated review.

Budd Chiari syndrome is a potentially treatable disease, and imaging is the key to its diagnosis. Clinical presentations may vary, ranging from asymptomatic to fulminant disease. Subacute BCS is the most common type encountered in clinical practice, characterized by ascites, hepatosplenomegaly, dilated abdominal wall veins, and varicosities in the lower limb and scrotum. While hepatic vein thrombosis is the leading cause in the West, membranous and short segmental occlusion are predominant in the Asian populations. These geographical variations have an impact on the treatment algorithm in managing BCS. Anticoagulation alone often fails to prevent disease progression, demanding further interventional therapy. Interventional therapy carries a lower morbidity and mortality than surgery. Anatomical recanalization and portosystemic shunting form the basis of endovascular management. Membranous or short-segment occlusion are best treated by angioplasty, which restores the physiological venous outflow and possibly disease reversal. Suboptimal results with angioplasty require stenting. Transjugular intrahepatic shunt (TIPS) or direct IVC to portal vein shunt (DIPS) decompresses the portal pressure and reduces the sinusoidal congestion, which in turn diminishes hepatocellular damage and hepatic fibrosis. Despite its ability to modify the disease course, TIPS carries several procedure and shunt-related complications, mainly hepatic encephalopathy. Thus, anatomical recanalization precedes TIPS in the traditional step-up approach in managing BCS. However, this concept is challenged by some authors, necessitating future reseach. TIPS is a valid bridge therapy in BCS with acute live failure awaiting liver transplantation. Despite all, interventional therapies fail in a subset of BCS patients, leaving them with only option of liver transplantation.

Treatment of Acute Iatrogenic Cerebrovascular Injury Using Flow Diverter Stents

BACKGROUND AND OBJECTIVES: Iatrogenic cerebrovascular injury can cause intracranial hemorrhage and pseudoaneurysm formation, putting patients at high risk for postoperative bleeding. No consensus for management exists. This study describes endovascular treatment of these acute injuries with flow diverter stents. METHODS: Electronic medical records were retrospectively reviewed for injury type and etiology, timing of diagnosis, and endovascular management, including antiplatelet regimens, embolization results, and clinical outcome. RESULTS: Six patients were included. Three suffered an injury to the internal carotid artery, 1 suffered an injury to the left anterior cerebral artery, 1 suffered an injury to the right posterior cerebral artery, and 1 suffered an injury to the basilar artery. Four of the 6 injuries occurred during attempted tumor resection, 1 occurred during cerebrospinal fluid leak repair, and 1 occurred during an ophthalmic artery aneurysm clipping. All injuries resulted in pseudoaneurysm formation. Four were immediately detected on angiography; 2 were initially negative on imaging. Five were treated with a pipeline embolization device, and 1 was treated with a Silk Vista Baby. Two were treated with 2 pipeline embolization devices telescopically overlapped across the pseudoaneurysm. All devices deployed successfully. No pseudoaneurysm recurrence or rebleeding occurred. No parent artery occlusion or stenosis was observed, and complete pseudoaneurysm occlusion was observed in 4 patients (in 2 patients, follow-up imaging could not be obtained). CONCLUSION: With proper antiplatelet regimens, flow diverter stents can be used safely to successfully treat complex acute iatrogenic injuries. Early repeat angiogram is needed when immediate postinjury imaging does not discover the point of vessel injury.

Case Report: Emergency endovascular management of a ruptured giant abdominal aortic aneurysm with severely angulated and conical shaped neck using novel multiple stiff wire technique

Background Ruptured abdominal aortic aneurysm (rAAA) is commonly fatal, with an overall mortality rate of nearly 90%, and the risk of subsequent rupture remains high, especially in large aneurysm diameters or progressive disease. Unfavorable neck anatomy in EVAR is linked to early graft failure and long-term complications. Recently, a novel multiple stiff wire (MSW) technique has been developed to overcome the challenges of hostile neck anatomy without introducing additional devices and procedural complexity. It has also been feasible in a series of elective cases. In this case, we report the first-ever utilization of the MSW technique in an emergency case of an acute contained rAAA with a conical-shaped, severely angulated neck who underwent Endovascular Aortic Repair (EVAR). Case presentation A 61-year-old man came with intermittent sharp stomach pain radiating to his back since three weeks ago. Physical examination showed elevated blood pressure and anemic conjunctiva. Laboratory examinations showed anemia, leukocytosis, elevated D-dimer level, high creatinine level, and low eGFR. CT-Scan Angiography (CTA) revealed severely hostile anatomy, a conical-shaped abdominal aorta aneurysm with a length of 13.2 cm and a maximum diameter of 9.3 cm with angulation of 90.1°. The patient was diagnosed with Ruptured AAA with a conical-shaped, severely angulated neck. Endovascular Aortic Repair (EVAR) management with MSW technique was planned for him. After four days, The patient was discharged in a clinically stable condition with optimal medical treatment and education. Conclusion The endovascular approach could be performed in emergency settings and has been proven to reduce length of stay, mortality, and morbidity rates. In this case, the endovascular approach with the MSW technique showed promising results for the patient.

Conventional and old endovascular techniques for vertebral aneurysms still work in the era of flow diversion

BackgroundEndovascular management for vertebral artery dissecting aneurysms (VADA) is quite intricate which thereby necessitate different strategies per case. Our current study described various optimal strategies available for endovascular management of VADA other than flow diverter (FD).Results14 Patients presented with acute SAH and 4 patients with symptoms of mass effect. VADA were classified in 3 groups, viz contralateral vertebral artery is dominant group A (n = 5), co-dominant group B (n = 8) or group C hypoplastic (n = 5). Group A and B (n = 13) was further subdivided into three subtypes depending on location of aneurysm with respect to posterior inferior cerebellar artery (PICA), aneurysm proximal to the PICA, type I (n = 5); involving the PICA, type II (n = 1); and distal to the pica, type III (n = 4). Treatment strategy varied with type whether deconstructive or reconstructive methods using stents and coils in different fashion.ConclusionPreprocedural angiographic work up delineating the anatomical location of the aneurysm, contralateral vertebral artery dominancy and nearby perforator status along with location of PICA is imperative in selecting the safest and optimal endovascular therapy option.

STABILISE for acute type B aortic dissection.

Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection (STABILISE) is an extended downstream endovascular management technique for acute type B aortic dissection (TBAD), that aimed to achieve complete aortic remodeling. This systematic review aimed to assess the early and mid-term clinical outcomes with STABILISE in the management of TBAD. A literature search was performed on the Medline, Web of Science, Scopus, and SciELO databases, which returned 195 studies. Five studies were included. Data were extracted using predefined forms. In total, one hundred patients with acute or subacute TBAD managed with STABILISE were included. All studies reported a technical success of 100%. Thirty-day mortality was estimated at 4% (4/100) with no further deaths documented during an estimated mean follow-up of 12.7 months (range 12-15 months). Five percent developed spinal cord ischemia and another 5% developed visceral artery occlusions. One case of aortic rupture during time of balloon inflation was reported. Rare complications included delayed retrograde dissection (1%), aortobronchial fistula (1%), and renal failure (1%). One case of disconnection between stent-graft and bare stent was documented. Six percent of patients developed endoleak, predominately type I. Overall re-intervention rate was 21%, as reported in all studies. Complete obliteration of the false lumen in the thoracic aorta was achieved in 99% of patients and in the abdominal aorta in 96% of patients. STABILISE technique carries promising early and mid-term outcomes with high technical success and low mortality and morbidity. Excellent results on complete false lumen obliteration were observed. However, the heterogeneity among available studies' methodology does not permit firm conclusions, and further prospective analyses are needed to study the long-term outcomes of STABILISE.

Prevention of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage-Summary of Existing Clinical Evidence.

The 2023 International Subarachnoid Hemorrhage Conference identified a need to provide an up-to-date review on prevention methods for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage and highlight areas for future research. A PubMed search was conducted for key factors contributing to development of delayed cerebral ischemia: anesthetics, antithrombotics, cerebrospinal fluid (CSF) diversion, hemodynamic, endovascular, and medical management. It was found that there is still a need for prospective studies analyzing the best methods for anesthetics and antithrombotics, though inhaled anesthetics and antiplatelets were found to have some advantages. Lumbar drains should increasingly be considered the first line of CSF diversion when applicable. Finally, maintaining euvolemia before and during vasospasm is recommended as there is no evidence supporting prophylactic spasmolysis or angioplasty. There is accumulating observational evidence, however, that intra-arterial spasmolysis with refractory DCI might be beneficial in patients not responding to induced hypertension. Nimodipine remains the medical therapy with the most support for prevention.

Endovascular vs Medical Management of Acute Basilar Artery Occlusion

In several randomized clinical trials, endovascular thrombectomy led to better functional outcomes than conventional treatment at 90 days poststroke in patients with acute basilar artery occlusion. However, the long-term clinical outcomes of these patients have not been well delineated. To evaluate 1-year clinical outcomes in patients with acute basilar artery occlusion following endovascular thrombectomy vs control. This study is an extension of the ATTENTION trial, a multicenter, randomized clinical trial. Patients were included between February 2021 and January 2022, with 1-year follow-up through April 2023. This multicenter, population-based study was conducted at 36 comprehensive stroke sites. Patients with acute basilar artery occlusion within 12 hours of estimated symptom onset were included. Of the 342 patients randomized in the ATTENTION trial, 330 (96.5%) had 1-year follow-up information available. Endovascular thrombectomy (thrombectomy group) vs best medical treatment (control group). The primary outcome was defined as a score of 0 to 3 on the modified Rankin Scale (mRS) at 1 year. Secondary outcomes were functional independence (mRS score 0-2), excellent outcome (mRS score 0-1), level of disability (distribution of all 7 mRS scores), mortality, and health-related quality of life at 1 year. Among 330 patients who had 1-year follow-up data, 227 (68.8%) were male, and the mean (SD) age was 67.0 (10.7) years. An mRS score 0 to 3 at 1 year was achieved by 99 of 222 patients (44.6%) in the thrombectomy group and 21 of 108 (19.4%) in the control group (adjusted rate ratio, 2.23; 95% CI, 1.51-3.29). Mortality at 1 year compared with 90 days was more frequent in both the thrombectomy group (101 of 222 [45.5%] vs 83 of 226 [36.7%]) and the control group (69 of 108 [63.9%] vs 63 of 114 [55.3%]). Excellent outcome (mRS score 0-1) at 1 year compared with 90 days increased in the thrombectomy group (62 of 222 [27.9%] vs 45 of 226 [19.9%]) but not in the control group (9 of 108 [8.3%] vs 9 of 114 [7.9%]) resulting in a magnified treatment benefit. Among patients with basilar artery occlusion within 12 hours of onset, the benefits of endovascular thrombectomy at 1 year compared with 90 days were sustained for favorable (mRS score 0-3) outcome and enhanced for excellent (mRS score 0-1) outcome.

Comparative Study between Mechanical Rotational Atherectomy Combined with Drug-Coated Balloon versus Drug-Coated Balloon Alone for Treatment of In-Stent Restenosis during Peripheral Endovascular Interventions: A Multicentric Trial

Purpose: To compare the efficacy and safety of percutaneous mechanical debulking (PMD) using mechanical rotational atherectomy combined with paclitaxel drug-coated balloon (DCB) versus using paclitaxel DCB alone in the treatment of in-stent restenosis. Material and Methods: This is a multicentric retrospective observational study conducted over a period of 2 years from 2020 to 2022. The study included 49 patients presented with chronic limb-threatening ischemia (CLTI) associated with in-stent restenosis, either acute (&lt;14 days), subacute (&lt;3 months) or chronic (&gt;3 months). The enrolled patients underwent endovascular revascularization using either PMD combined with paclitaxel DCB or paclitaxel DCB only. They were followed up for 6 months after the intervention clinically and by duplex evaluation. Results: The lesion length was about 14.2 mm in the group treated by PMD+ DCB and 9.3 mm in the group treated by DCB alone. The technical success rate was the same between the two groups. However, the follow-up after 6 months showed that patencies for PMD + DCB and DCB alone were 15 (68.2%) patients and 15 (55.6%) patients, respectively (significant p value = 0.028). Procedural-related complications for PMD + DCB are distal embolization (9%) of cases and no vessel perforation. Regarding the candidates who were treated by DCB alone, there were minor groin hematomas (11.1%), distal arterial thrombosis (11.1%) and contrast-induced nephropathy (CIN) (11.1%) cases. Conclusion: The endovascular management of in-stent restenosis using percutaneous mechanical debulking (PMD) in conjunction with paclitaxel drug-coated balloon (DCB) showed that PMD combined with DCB is a safe and effective modality for achieving recanalization. It gives a satisfactory outcome in terms of technical success, freedom from clinically driven target lesion revascularization rate (CD-TLR) and mortality. Despite these promising results, further research with a large enrolled population may be required to determine the cost/benefit.

Staged cerebral and brachiocephalic bypass in a patient with MCA and brachiocephalic steno-occlusion.

Background: Brachiocephalic steal is a rare phenomenon that may lead to hemodynamic abnormalities in the ipsilateral vertebral and carotid arteries. Current treatment includes management of vascular risk factors, endovascular stenting, and surgical management depending on the severity of symptoms. Case Information: We describe a patient with multiple vascular risk factors who presented with mild neurological symptoms and chronic right arm weakness associated with concurrent brachiocephalic steal and right MCA M1 stenosis on neuroimaging. Use of right superficial temporal artery to middle cerebral artery bypass and aorta-right subclavian bypass resulted in improved flow to the right hemisphere on quantitative magnetic resonance angiography and single-photon emission computed tomography, significantly lowering the risk of catastrophic ischemic stroke. Conclusion: Complex steal phenomena increase stroke risk. In cases of high-grade occlusion or advanced symptoms, endovascular or surgical management should be considered for optimal stroke prevention.

Endovascular Management of Basilar Artery Aneurysms: A Consecutive Series of 124 Patients

There is currently no established criterion for determining when interventional treatment is necessary and what strategy is appropriate for basilar artery (BA) aneurysms. Through this study, we aimed to propose an algorithm that can effectively determine the optimal endovascular treatment (EVT) option for BA aneurysms. We enrolled patients with BA aneurysms from June 2016 to December 2022 and performed procedures based on the algorithm. The analysis included demographic, clinical, and aneurysmal characteristics, procedural details, complications, angiographic outcomes, and clinical outcomes. This study included 124 patients (mean age 55.0 years) with a BA aneurysm who underwent EVT. Of these, 21 aneurysms were treated in the setting of subarachnoid hemorrhage (SAH). The majority of aneurysms were located at the basilar apex (74), followed by the basilar trunk (30) and vertebrobasilar junction (20). Coiling was used in 18.5% of cases, while stent-assisted coiling embolization was chosen for 58.9%. Overlapping stents were used in 12.9%, flow diverter (FD) implantation in 3.2%, Y/T stent techniques in 4.8%, and stent adjunctive coiling with unilateral vertebral artery (VA) occlusion in only 1.6%. Procedure-related complications occurred in 15 patients (12.1%). Patients had a modified Rankin Scale(mRS) score of 0.74±1.62; 98 (86.7%) had good prognosis with mRS scores ranging from 0 to 2 at the last follow-up. DSA was performed on 105 (84.7%) patients revealing that 101 (81.5%) achieved complete or near-complete occlusion. The endovascular treatment criteria for BA aneurysms depended on the multi-characteristics was safe and effective. However, further evidence is needed from large cohort studies.

Perianeurysmal vasogenic oedema (PAVO): A single centre 10-year retrospective review.

Perianeurysmal Vasogenic Oedema (PAVO) is a rare but important complication of endovascular treatment of intracranial aneurysms. Many potential risk factors have been identified including age, aneurysm size, aneurysm location, immunological profile, type of coil used, diabetes, hypertension, and smoking. PAVO can cause persistent post-procedural symptoms, subsequently increasing post-embolization morbidity. A 10-year retrospective review was conducted between 2011 and 2021 at Royal Preston Hospital, Preston, UK. We identified 8 patients that fit our inclusion criteria. This included 6 (75%) females and 2 (25%) males. The mean age was 64. All patients had anterior circulation aneurysms with the middle cerebral artery (MCA) being the most common site. The mean aneurysm size was 12mm. Our patients were managed with a range of endovascular techniques. One patient had pre-treatment PAVO while 7 patients had post-embolization PAVO. Five patients were symptomatic, and 3 cases were asymptomatic with only radiological evidence of PAVO. Five patients were managed with varying courses of dexamethasone. PAVO resolution was achieved in 4 cases. The oedema significantly improved in 3 cases, but transiently progressed in 1 case. PAVO is a rare but important complication of endovascular management of intracranial aneurysms. We have shown that patients can be effectively managed with steroids with resultant oedema regression and symptomatic improvement. Many risk factors have been associated with PAVO, but further research is needed to better understand their role in PAVO development and help develop other therapeutic options.