Endovascular Management Research Articles

Accurate low-energy pulse system for intravascular lithotripsy

In response to biomedical imperatives, a novel approach is presented for the endovascular management of atherosclerosis. This approach is grounded in the electrohydraulic effect of a precisely controlled low-energy pulse discharge system, coupled with sequential control within the incomplete discharge electrode, to generate shockwaves aimed at softening blood vessels and rupturing calcified plaques. Theoretical analysis encompassed circuit design, control timing, and operational processes, while experimental investigations demonstrated precise control of non-oscillation and incomplete discharge by adjusting key parameters. Utilizing a 3 kV DC high-voltage power supply, a 220 nF capacitor, and two sets of 3.3 Ω resistors in parallel, with pin–plate electrodes as the load for discharge in normal saline, resulted in a 1 kV reduction in voltage across the capacitor and a peak current of 170 A. Energy release occurred through non-oscillatory and incomplete discharge, effectively generating shockwaves with peak pressures of 5–10 MPa at distances of 1–2 mm from the discharge center to treat calcified lesions. Compared with the existing intravascular lithotripsy devices, the shockwave system realizes accurate control of discharge energy by adjusting the turn-off time of incomplete discharge so as to realize accurate control of shockwave energy. Doctors can choose different intensities of shockwaves according to different degrees of calcification in the treatment process so as to minimize the discomfort caused by shockwaves and improve safety. Valuable insights are provided for intravascular lithotripsy devices in engineering.

218 Cost-Effectiveness and Quality-Adjusted Life Years Analysis for Endovascular Management of Acute Stroke With a Large Ischemic Region

INTRODUCTION: Mechanical thrombectomy (MT) for acute ischemic stroke is generally avoided when the infarction is large (defined as ASPECT score of < 5). However, a recent trial (RESCUE-Japan) published in NEJM, showed that patients with large cerebral infarctions had better functional outcomes, measured as mRS of 0-3 at 90 days, with MT compared to best medical management (BMM) alone. METHODS: Treeage, a decision-analytic software, was used to construct a cost effectiveness analysis model that compares the cost-effectiveness of MT vs. BMM alone based on the RESCUE-Japan study. The model includes a short-term decision model that examines costs and clinical outcomes of patients with acute ischemic stroke during the initial three months of treatment. Additionally, a long-term Markov state transition model is created to estimate expected outcomes and costs annually over a 20-year timeframe, with patients potentially experiencing recurrent strokes, transitioning to lower health states, and death from stroke. The success of each treatment was evaluated using QALYs. Then, to assess the robustness of this model, a sensitivity analysis was performed. RESULTS: In the base–case analysis of the total study population using a time horizon of 20 years, MT and BMM alone were found to have a 2.86 QALY and 1.44 QALY, respectively. This increase in the number of QALY by MT came at a lower cost of $275,805 compared to BMM alone, which had a cost $282,476. The incremental cost-effectiveness ratio (ICER) was determined at $-4697/QALY. The results were further supported by the 1-way deterministic and probabilistic sensitivity analyses. CONCLUSIONS: This study shows that, besides having a better clinical outcome, MT was more cost effective and associated with higher QALYs compared to BMM alone, when accounting for health care cost associated with treatment outcome.

Endovascular treatment of vein of Galen aneurysmal malformation: hospital-based case series in two tertiary centers

BackgroundVein of Galen aneurysmal malformation (VGAM) is considered a rare vascular malformation, constituting over 1% of all arteriovenous shunts. This malformation represents around 30% of congenital vascular malformations in the pediatric population. The focus of our study is to examine both the clinical and radiological outcomes following endovascular embolization in pediatric patients with Galenic arteriovenous shunts. Our aim is to evaluate the safety and efficacy of endovascular management. This research aims to contribute to understanding the management and outcomes of VGAM in pediatric patients, particularly in the context of endovascular embolization.MethodThis study included 19 patients with vein of Galen malformation evaluated clinically and radiologically and we treated them with endovascular embolization with aim to assess safety and efficacy of endovascular treatment of VGA in the period from May 2019 to December 2022.ResultsWe evaluated 12 male patients 63.2% and 7 females 36.8% in pediatric age group with vein of Galen malformation. Patients were followed for 1 year. Our study included 3 neonates (15.8%), 10 infants (52.6%) and 6 children (2–10 years) (31.6%). Increase SC (skull circumference) was the most common presenting symptoms 8 (42.1%). We have reached total occlusion in 15 patients (78.9%) while 4 patients had residual (21.1%). 11 patients improved (57.9%) and 2 patients died (10.5%).ConclusionVGAM are not very rare and should be kept in mind in children with refractory heart failure. Introduction of endovascular embolization as the primary therapy has significantly improved prognosis. Good selection of cases based on their score and good timing of treatment has impact on prognosis with less morbidities.

A case report of endovascular treatment of a fast-growing inflammatory abdominal aortic aneurysm in a patient with Staphylococcus aureus sepsis

Abdominal Aortic Aneurysm (AAA) and its subsequent rupture is one of the life-threatening conditions. The most common type of arterial aneurysm, AAA, becomes significant at a diameter greater than 3 cm. The mean growth rate of an AAA is 2-3 mm per year, and surgical repair is usually recommended if the diameter exceeds 5.5 cm, in men and 5.0 to 5.2 cm, in women. Faster-growing aneurysms are more aggressive and have a greater risk of rupture. We report a case of a 64-year-old, comorbid male patient who was found to have a previously unknown, but a rapidly growing AAA, which grew from 6cm to 8 cm within just 3 weeks. He was admitted in the emergency department with complaints of worsening dyspnea even without exertion. Upon thorough diagnostic tests, the severity of the overall medical condition was determined by S. aureus sepsis, decompensation of cardiovascular disease, and secondary kidney injury due to septic shock. While receiving treatment for sepsis, a diagnostic CT imaging was done, which confirmed bilateral pneumonia and retroperitoneal abscess in m. psoas major mass, and an infrarenal abdominal aortic aneurysm, which was 6cm in diameter at the time of diagnosis. Another control CT of the lungs and abdomen was performed three weeks later, indicating the pneumonia was slowly resolving, while the aortic aneurysm increased in dynamic; the diameter was 8 cm with a penetrating exudation on the left side, m. psoas abscess was still observed, but decreasing. Because the AAA was very fast-growing, it greatly increased the risk of its rupture, therefore a decision was made to perform endovascular abdominal aortic aneurysm repair, despite the risk of stent infection, given the patients septic background. The goal of this case report is to highlight the rare case of a rapidly growing inflammatory aneurysm and its successful endovascular management. While it’s known that 5-10% of all AAA are inflammatory, cases of surgical treatment in the setting of sepsis are basically non-existent in the literature [1].

Endovascular management of a ruptured hepatic artery pseudoaneurysm after liver transplantation presenting as hemobilia

Vascular and biliary complications can still occur among liver transplants despite advances in surgical technique and immunosuppression. Rupture of a hepatic artery pseudoaneurysm is a rare but lethal complication after liver transplantation and often manifests as acute gastrointestinal bleeding. It occurs in < 3% of cases with an associated mortality as high as 50% especially if diagnosed late. A high index of suspicion may decrease consequent morbidities and potential graft loss. Infection and type of biliary anastomosis are commonly identified risk factors in the development of a pseudoaneurysm. Angiography usually identifies the location which is commonly at the site of anastomosis. Frequent management options include surgical revascularization requiring re-operation or endovascular intervention with the use of coils and stents. No consensus yet as to the standard treatment has been established. We present a case of a 40-year-old male having a ruptured hepatic artery pseudoaneurysm with an arteriobiliary fistula after performing a deceased donor liver transplant managed with endovascular placement of a stent. Patient remains asymptomatic with patent hepatic artery after 6 months of follow-up.

Inferior Pancreaticoduodenal Artery Pseudoaneurysm Causing Biliary Obstruction: A Case Report.

Visceral arterial aneurysms and pseudoaneurysms are rare but dangerous pathologies, with reported incidence of 0.01-0.2% of the worldwide population, as found on autopsy. Pancreaticoduodenal artery pathology accounts for approximately 2% of all visceral aneurysms; it is commonly caused by chronic inflammatory processes, such as pancreatitis or adjacent pseudocysts. Morbidity and mortality commonly result from rupture of the aneurysm itself, leading to life-threatening hemorrhage into the peritoneum or gastrointestinal tract. Here we present the case of a 64-year-old male patient with previous history of alcohol use disorder leading to chronic pancreatitis and prior embolization of an inferior pancreaticoduodenal pseudoaneurysm, who presented to the emergency department (ED) with abdominal pain, nausea, and vomiting, and was found to have a large recurrent inferior pancreaticoduodenal pseudoaneurysm with associated obstructive cholangitis and pancreatitis via contrast-enhanced computed tomography (CT) of the abdomen and pelvis. The patient was managed emergently by interventional radiology angiography with embolic coiling and percutaneous biliary catheter placement, and he subsequently underwent biliary duct stenting with gastroenterology. The patient was successfully discharged after a brief hospitalization after resolution of his pancreatitis and associated hyperbilirubinemia. Pancreaticoduodenal artery aneurysms and pseudoaneurysms are rare and dangerous visceral pathologies. Patients can be diagnosed rapidly in the ED with CT imaging and need urgent endovascular management to prevent morbidity and mortality.

Trading Scalpel and Sutures With Guidewires and Catheters: Endovascular Management of Extremity Vascular Trauma

Trading Scalpel and Sutures With Guidewires and Catheters: Endovascular Management of Extremity Vascular Trauma

The role of the vascular surgeon in transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) has become the standard treatment for severe aortic valve stenosis in patients at increased surgical risk. Percutaneous transfemoral (TF) is the access of choice due to its reduced invasiveness and perioperative morbidity/mortality compared with the trans-axillary, aortic, and apical routes. On the other hand, vascular access complications (VACs) of the TF access are associated with prolonged hospitalization, 30-day, and 1-year mortality. In addition, the concomitance of peripheral arterial disease may require associated endovascular management. A multidisciplinary team with Interventional Cardiologists and Vascular Surgeons may minimize the rate of VACs in patients with challenging femoral-iliac access or concomitant disease of other vascular districts, thus optimizing the outcome of TF-TAVI. The aim of this study was to evaluate the role of Vascular Surgeons in TF TAVI procedures. We conducted a retrospective single-center review of all TF-TAVI procedures assisted by Vascular Surgeons between January 2016 and December 2020 in a high-volume tertiary hospital. Pre, intra, and postoperative data were analyzed by a dedicated group of Interventional Cardiologists and Vascular Surgeons. VACs were defined according with the Valve Academic Research Consortium (VARC) three guidelines. The outcomes of TF-TAVI procedures with Vascular Surgeons involvement were assessed as study's endpoints. Overall, 937 TAVI procedures were performed with a TF approach ranging between 78% (2016) and 98% (2020). Vascular Surgeons were involved in 67 (7%) procedures with the following indications: concomitant abdominal aortic aneurysm (EVAR + TAVI) - 3 (4%), carotid stenosis (TAVI + CAS) - 2 (3%), hostile femoral/iliac access, or VACs - 62 (93%). Balloon angioplasty of iliac artery pre-TAVI implantation was performed in 51 cases (conventional PTA: 38/51%-75%; conventional PTA + intravascular lithotripsy: 13/51%-25%; stenting: 5/51%-10%). TAVI procedure was successfully completed by percutaneous TF approach in all 62 cases with challenging femoral/iliac access. VACs necessitating interventions were 18/937 (2%) cases, localized to the common femoral or common/external iliac artery in 15/18 (83%) and 3/18 (17%) cases, respectively. They were managed by surgical or endovascular maneuvers in 3/18 (17%) and 15/18 (83%) cases, respectively. Fifteen/18 (83%) VACs were treated during the index procedure. There was no procedure-related mortality or 30-day readmission. In our experience, Vascular Surgeon assistance in TAVI procedures was not infrequent and allowed safe and effective device introduction through challenging TF access. Similarly, the concomitant significant disease of other vascular districts could be safely addressed, potentially reducing postoperative related mortality and morbidity. The implementation of multidisciplinary team with interventional cardiologists and vascular surgeons should be encouraged whenever possible.

Endovascular Management of Iatrogenic Neck Vascular Injury after Central Venous Catheterisation

Endovascular Management of Iatrogenic Neck Vascular Injury after Central Venous Catheterisation

Effectiveness of Endovascular Management of Chronic Pelvic Pain in Pelvic Congestion Syndrome Type I

Effectiveness of Endovascular Management of Chronic Pelvic Pain in Pelvic Congestion Syndrome Type I

Endovascular Management of Pelvic Trauma: The Interventional Radiology Point of View

Background: Traumatic pelvic injuries are associated with high injury severity scores and significant morbidity and mortality. Active bleeding is the most common cause of death among those patients. Due to limitations of surgery for pelvic hematomas, angiographic treatment is at the forefront of pelvic trauma management.Objective: The present article aims to discuss the available endovascular treatment modalities, and common angiographic treatment strategies and techniques.Conclusion: Interventional radiologists plays a key role in the management of patients with pelvic trauma. New standardized protocols are needed to minimize the time spent on deciding the correct treatment for each patient.

3D digital subtracted angiography venous roadmapping for endovascular management of dural venous stenosis.

Stenting of the dural venous sinuses has emerged as a therapeutic option for intracranial hypertension and pulsatile tinnitus. However, venous endovascular navigation faces challenges due to lower-quality roadmaps compared to arterial navigation. This study explores the application of three-dimensional (3D) rotational venography in assessing the cerebral venous vasculature and its potential for venous navigation. The methods involve venous 3D digital subtracted angiography (DSA) in patients with dural venous stenosis, with image acquisition using a biplane angiographic system. The results highlight the enhanced spatial resolution of 3D venous imaging, providing anatomical information crucial for precise characterization of stenosis and understanding cortical venous drainage. 3D venous roadmapping is shown to improve endovascular venous navigation, offering synchronized and rotatable 3D roadmaps, providing a comprehensive approach to optimize endovascular venous interventions.

Short-term outcomes of endovascular management of acute limb ischemia using aspiration mechanical thrombectomy.

Management of acute limb ischemia (ALI) has seen greater utilization of catheter-based interventions over the last two decades. Data on their efficacy is largely based on comparisons of catheter-directed thrombolysis (CDT) and open thrombectomy. During this time, many adjuncts to CDT have emerged with different mechanisms of action, including pharmacomechanical thrombolysis (PMT) and aspiration mechanical thrombectomy (AMT). However, the safety and efficacy of newer adjuncts like AMT have not been well established. This study is a retrospective analysis of the contemporary management of ALI comparing patients treated with aspiration mechanical thrombectomy to patients treated with the more established CDT adjunct, pharmacomechanical thrombolysis. Patients undergoing peripheral endovascular intervention for ALI using an adjunctive device were identified through query of the Vascular Quality Initiative (VQI) Peripheral Vascular Intervention (PVI) module from 2014 to 2019. Patients with a nonviable extremity (Rutherford ALI Stage 3), prior history of ipsilateral major amputation, popliteal aneurysm, procedures that were deemed elective (>72h from admission), procedures that did not utilize an endovascular adjunctive device, and patients without short-term follow-up were all excluded from analysis. The primary outcome was a composite outcome of freedom from major amputation and/or death in the perioperative time period. We identified 528 patients with Rutherford ALI Stage 1 or 2 who were treated with an endovascular adjunct. 433 patients did not undergo aspiration mechanical thrombectomy (no AMT group) and 95 patients did undergo aspiration mechanical thrombectomy (AMT group). The amputation-free survival across all patients was 93.4%. There were significant differences in demographic, comorbidity, and treatment variables between groups (e.g., gender, prior percutaneous coronary intervention (PCI), history of prior peripheral artery disease intervention, and history of prior infra-inguinal PVI), so a propensity score matched analysis was included to account for these group differences. In the propensity score matched analysis, there was no significant difference in major amputation (AMT 7.4% vs no AMT 3.2%, p = 0.13) or death (AMT 95.8% survival vs no AMT 98.4% survival, p = 0.23) with the use of aspiration mechanical thrombectomy. However, there was significantly worse amputation-free survival with the use of aspiration mechanical thrombectomy (AMT 88.4% vs no AMT 95.3%, p = 0.03). On multivariate analysis, prior supra-inguinal bypass (OR 4.85, 1.70-13.84, p = 0.003), Rutherford ALI Stage 2B (OR 3.13, 1.47-6.67, p = 0.003), and aspiration mechanical thrombectomy (OR 2.71, 1.03-7.17, p = 0.05) were associated with the composite outcome. Short-term amputation-free survival rates of endovascular management of acute limb ischemia are adequate across all modalities. However, aspiration mechanical thrombectomy was associated with significantly worse amputation-free survival compared to other endovascular adjuncts alone (i.e., pharmacomechanical thrombolysis). Severe limb ischemia (Rutherford ALI Stage 2B) and prior supra-inguinal bypass were associated with worse amputation-free survival regardless of the choice of endovascular intervention.

Endovascular management of acute and subacute venous thoracic outlet syndrome.

Approximately 3% of all patients presenting with Thoracic Outlet Syndrome have a venous etiology (vTOS), which is considered "effort thrombosis". These patients will present with symptomatic deep venous thrombosis or focal subclavian vein (SCV) stenosis. Endovascular management of vTOS occurs in several phases: diagnostic, preoperative therapeutic intervention before decompression, postoperative interventions after decompression, and delayed interventions in the follow-up after decompression. In the diagnostic phase, dynamic SCV venography can establish functional vTOS. Approximately 4,000 patients have been treated for vTOS and reported in the literature since 1970. Declotting of the SCV was followed by surgical decompression in 53% of patients, while in the remainder, surgical decompression alone (18%), endovascular intervention alone (15%), or conservative therapy with anticoagulation (15%) was performed. The initial intervention was predominantly catheter-directed thrombolysis, with <10% of cases undergoing concomitant balloon angioplasty. 93% of cases were successful. In the postoperative phase, balloon angioplasty was performed to correct residual intrinsic SCV disease after vTOS decompression in under 15% of cases. Stents were rarely deployed. Symptom relief was reported as 94 ± 12% (mean ± SD) and 90 ± 23%, respectively for declotting with decompression and declotting alone. In the delayed phase, balloon angioplasty was performed in under 15% of cases to re-establish patency.

Abstract WP221: Vein of Galen Malformations: Twenty Years Later

Introduction: Vein of Galen Malformations (VOGM) are congenital arteriovenous malformations which carry a mortality of 76.7% in untreated patients. Outcomes have improved over time with advances in endovascular embolization. As endovascular management of VOGM has begun to favor more aggressive treatment strategies, there is scarce literature examining long-term functional and neurological outcomes and whether patients may have benefited from a more or less aggressive approach to treatment. Methods: A single-center retrospective review identified all patients with VOGM over the age of 18 with complete clinical data from January 1982 to May 2005. Patients were stratified based on radiographic outcomes: cured before the age of 18 (“pediatric-cured group”), cured after the age of 18, or not cured. Patients cured after the age of 18 and patients who were never cured were grouped together (“adult-cured group”). Long-term functional outcomes were assessed using the modified Rankin Scale (mRS). Statistical analyses were conducted in R version 4.2.1. Results: Forty-three adult patients were identified: 26 in the pediatric-cured group and 17 in the adult-cured group. The median current age of the pediatric-cured group was less than the adult-cured group (21 vs. 28, p&lt;0.01). On initial presentation, the groups did not differ in their clinical or radiographic symptoms, comorbidities, or developmental delays. No significant differences were present in treatment courses. The pediatric-cured group demonstrated lower risk of intraprocedural or postprocedural hemorrhagic complications (p=0.03). On long-term follow-up, adult-cured patients presented with worse mRS (p&lt;0.01), a higher rate of neurological symptoms (p&lt;0.01), persistent fine motor delays (p&lt;0.03), persistent cognitive or learning deficits (p=0.04), and persistent hydrogenous disorder (p&lt;0.01). Conclusion: This is the first study to analyze long-term outcomes of adult patients managed for VOGM during the pediatric period. Patients cured in the pediatric period demonstrated reduced risk of hemorrhagic complications and improved long-term functional and neurological outcomes. Pursuing early cure in patients with VOGM may provide long-term benefit and reduce risk in later treatment.

Abstract TP215: Endovascular and Medical Management Strategies for Caroticocavernous Fistulae: A Single Center Retrospective Safety and Efficacy Analysis

Background: Caroticocavernous fistulae (CCF) are a rare subtype of intracranial arteriovenous fistulae with variable clinical and angiographic presentations. This study aimed to describe the clinical outcomes in a cohort of CCF patients and identify clinical and angiographic features differentiating patients more likely to benefit from endovascular intervention. Methods: A single-center, retrospective analysis was performed to identify all patients with angiographically-confirmed CCF between 2000 and 2022. Pertinent data, including clinical symptoms, angiographic findings, treatment strategies, recurrence rates, and complications, was collected. Results: A total of 84 patients were included, of whom 67 (80%) underwent endovascular intervention and 17 (20%) were conservatively managed. Primary endovascular techniques were transvenous coil embolization (78%), feeder artery embolization (16%), and ICA flow diversion (8%). High-risk clinical symptoms, such as reduced visual acuity, and angiographic features, such as cortical and ophthalmic venous reflux, were more common in the intervention group (p&lt;0.05). All direct (Barrow Type A) CCFs underwent endovascular intervention (32% vs 0%, p=0.005), while indirect (Barrow types B-D) CCFs were common in the conservatively managed group (100% vs 68%, p=0.005). 31% of treated CCFs required retreatment, which primarily occurred with Barrow type D CCFs and following transvenous coil embolization. Procedure-related complications occurred in 10% of cases and consisted of cranial nerve palsies (n=5), asymptomatic intracranial dissection (n=1), and asymptomatic distal thromboembolic occlusion (n=1). Conclusion: High-risk symptoms and angiographic features favor endovascular intervention. Various embolization techniques, including transvenous coil embolization, proved safe and effective. In select CCF patients without high-risk clinical or angiographic features, conservative observation is a safe and effective alternative to endovascular embolization. Complications were rare, and most were transient, emphasizing the safety of endovascular management. Longitudinal angiographic surveillance is essential for monitoring fistula persistence or recurrence.

Abstract 86: Outcomes of Endovascular Therapy for Late Large Vessel Occlusion in Patients With Pre-Stroke Disability

Background: There is a paucity of research to develop evidence-based recommendations for endovascular management in the extended time window (&gt;6 hours after time last seen well [TLSW]) for large vessel occlusion (LVO) patients with pre-stroke disability. Methods: We analyzed data from a multinational cohort (66 sites, 10 countries from 2014 to 2022) of acute ischemic stroke patients with pre-stroke modified Rankin Scale (mRS) 0-4 and anterior or posterior circulation LVO who received endovascular therapy 6-24 hours after TLSW. The primary outcome was the composite of functional independence (FI, mRS 0-2) or return to pre-stroke mRS (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS 2-4) vs those without (mRS 0-1). Results: There were 2231 patients (median age 77 years; median NIH Stroke Scale 16) included in the present study, of whom 564 (25.3%) had pre-stroke disability. The primary outcome (FI or ROR) was seen in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR 30.7%), compared with 44.1% of those without (FI, 44.1%; RoR 13.0%) ( P &lt;0.0001, Figure 1 ). In both multivariable logistic regression and inverse probability of treatment weighting analysis, pre-stroke disability was not associated with a lower odds of achieving FI or RoR (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.50-1.15 and aOR 0.73, 95% CI 0.43-1.25, respectively). FI or ROR was achieved at a higher percentage with reperfusion with mTICI ≥2b than with mTICI 0-2a, both in patients with pre-stroke disability (34.8% vs 10.8%, P &lt;0.0001) and in those without (49.2% vs 12.1%, P &lt;0.0001). Symptomatic intracranial hemorrhage occurred in 6.3% in both groups ( P =0.995). Conclusions: A substantial proportion of late LVO patients with pre-stroke disability regained pre-stroke mRS after EVT and did not have a worse functional prognosis than patients without pre-stroke disability when their pre-stroke mRS was considered.

Challenging Endovascular Treatment of Ruptured Proximal Posterior Inferior Cerebellar Artery Aneurysm: A Case Report

Highlight: Posterior inferior cerebellar artery (PICA) aneurysms are rare in occurence. The endovascular management of PICA aneursysms is challenging due to anatomical difficulties in accessing the site. The rebleeding of PICA aneurysms, although rare than other intracranial anurysms, may still happen and must be considered in their management ABSTRACT Introduction Aneurysms of the posterior inferior cerebellar artery (PICA) are rare clinical entities with a lower risk of rupture than other intracranial locations. This makes managing PICA aneurysms challenging and important for neurointerventionists to understand. In this case report, we looked at a rare case of PICA aneurysm with post-coiling rebleeding. Case: We reported a 51-year-old female with complaints of dizziness and vomiting. The patient was found to be hypertensive and a neurologic assessment revealed neck stiffness and left hemiparesis. A computed tomography (CT) scan of the head indicated subarachnoid hemorrhage. CT angiography (CTA) showed an aneurysm at the right proximal PICA. Although endovascular coiling was performed, the patient rebleed one month later. Following the insertion of the second coil, successful embolization was achieved, and the patient showed clinical improvement. Conclusion: PICA aneurysms require careful endovascular management, considering the difficulty of access due to their anatomical location. An understanding of its proper management is of paramount importance to reducing mortality.

Patterns of Care in the Diagnosis and Management of Intracranial Atherosclerosis‐Related Large‐Vessel Occlusion: The Rescue‐LVO Survey

Background We aimed to determine the current practice patterns among neurointerventional practitioners frequently involved in treating intracranial atherosclerosis‐related large‐vessel occlusion (ICAS‐LVO) during mechanical thrombectomy. Methods We conducted an international online survey of neurointerventionalist members of the Society of Vascular and Interventional Neurology and Society of Neurointerventional Surgery. The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO. Results A total of 184 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 38.3% reported an incidence of 6% to 10% of ICAS‐LVO during mechanical thrombectomy. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis after multiple mechanical thrombectomy attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS)±angioplasty. However, in patients who achieved recanalization with a severe fixed focal stenosis, most (58%) recommended primary medical management. The preferred medication during acute RS was intravenous antiplatelet therapy (65%), and after acute RS, it was dual oral antiplatelet therapy (65%). Fear of hemorrhagic complications (74%) was the most compelling reason not to perform RS±angioplasty. Of respondents, 24% were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before mechanical thrombectomy treatment. Conclusions The findings of this survey highlight the variations in practice in the medical and endovascular management of ICAS‐LVO. In addition, it informs the situation of equipoise in the treatment decision in ICAS‐LVO, which can then be incorporated into the design of future randomized clinical trials.

Endovascular Treatment of Anterior Inferior Cerebellar Artery Aneurysms: A Single-Center Experience and Review of 33 Patients

Objective: The aim of the present article was the demonstration of the institutional experience with the endovascular management of the anterior inferior cerebellar artery (AICA) aneurysms in order to propose a treatment algorithm. Methods: Clinical data were obtained from 33 patients with 37 AICA aneurysms who had been surgically treated at the authors’ hospital between 2010 and 2022. The patients’ medical records, imaging data, and follow-up outcomes were retrospectively analyzed. Results: All 33 patients (10 males, 23 females; mean age 54.88 ± 12.49 years) underwent endovascular therapy for AICA aneurysms. The most common chief complaints were headache (87.9%), nausea and vomiting (57.6%), and alteration of consciousness (27.3%). Thirty-one patients experienced subarachnoid hemorrhage. Regarding the AICA aneurysm location, 23 aneurysms were found at the right side of AICA in digital subtraction angiography images, and there were 6, 9, 16, 6 aneurysms in segments A1-A4, respectively. Coiling (59.5%), Onyx embolization (29.7%), coiling-combined Onyx embolization (5.4%), nonintervention (5.4%) were chosen in the surgical strategy. The length of follow-up was 8.09 ± 5.05 months, and 84.8% of the patients had favorable modified Rankin Scale (mRS) scores. The complete occlusion rates were 94.6%. Postoperative complications occurred in 4 cases (12.1%), including new neurological deficit in 3 cases and cerebral infarction in 1 case. One patient died after follow-up because of the severe pneumonia. Poor initial Hunt and Hess grade (HHG) (p = 0.007) was the risk factor for unfavorable clinical outcome. The rupture status (p = 0.025) and the location (p = 0.021) of the AICA aneurysms are statistically significant in determining which operation strategy to be chosen. Coiling had an advantage over Onyx embolization (p = 0.001) in parent artery preservation. Conclusions: In this study, an algorithm for the treatment of AICA aneurysms was proposed based on the clinical status of the patients before treatment, the anatomical factors of AICA, and the technical conditions of endovascular treatment (EVT). To our knowledge, this is the first study to report more than 30 cases of AICA aneurysms that had been treated by EVT and to advocate a treatment algorithm. EVT of AICA aneurysms is an optional strategy, but decisions are made based on the specific condition, anatomical location, and other factors.