Endovascular Treatment In Patients Research Articles

Effectiveness and safety of EVT in patients with acute LVO and low NIHSS.

Background and purposeThere is much uncertainty in endovascular treatment (EVT) decisions in patients with acute large vessel occlusion (LVO) and mild neurological deficits.MethodsFrom a prospective, nationwide stroke registry, all patients with LVO and baseline NIHSS <6 presenting within 24 h from the time last known well (LKW) were included. Early neurological deterioration (END) developed before EVT was prospectively collected as an increasing total NIHSS score ≥2 or any worsening of the NIHSS consciousness or motor subscores during hospitalization not related to EVT. Significant hemorrhage was defined as PH2 hemorrhagic transformation or hemorrhage at a remote site. The modified Rankin Scale (mRS) was prospectively collected at 3 months.ResultsAmong 1,083 patients, 149 (14%) patients received EVT after a median of 5.9 [3.6–12.3] h after LKW. In propensity score-matched analyses, EVT was not associated with mRS 0-1 (matched OR 0.99 [0.63–1.54]) but increased the risk of a significant hemorrhage (matched OR, 4.51 [1.59–12.80]). Extraneous END occurred in 207 (19%) patients after a median of 24.5 h [IQR, 13.5–41.9 h] after LKW (incidence rate, 1.41 [95% CI, 1.23–1.62] per 100 person-hours). END unrelated to EVT showed a tendency to modify the effectiveness of EVT (P-for-interaction, 0.08), which decreased the odds of having mRS 0–1 in mild LVO patients without END (adjusted OR, 0.63 [0.40–0.99]).ConclusionsThe use of EVT in patients with acute LVO and low NIHSS scores may require the assessment of individual risks of early deterioration, hemorrhagic complications and expected benefit.

Neurosurgical versus endovascular treatment of craniocervical junction arteriovenous fistulas: a multicenter cohort study of 97 patients.

Craniocervical junction (CCJ) arteriovenous fistulas (AVFs) are treated using neurosurgical or endovascular options; however, there is still no consensus on the safest and most effective treatment. The present study compared the treatment results of neurosurgical and endovascular procedures for CCJ AVFs, specifically regarding retreatment, complications, and outcomes. This was a multicenter cohort study authorized by the Neurospinal Society of Japan. Data on consecutive patients with CCJ AVFs who underwent neurosurgical or endovascular treatment between 2009 and 2019 at 29 centers were analyzed. The primary endpoint was the retreatment rate by procedure. Secondary endpoints were the overall complication rate, the ischemic complication rate, the mortality rate, posttreatment changes in the neurological status, independent risk factors for retreatment, and poor outcomes. Ninety-seven patients underwent neurosurgical (78 patients) or endovascular (19 patients) treatment. Retreatment rates were 2.6% (2/78 patients) in the neurosurgery group and 63% (12/19 patients) in the endovascular group (p < 0.001). Overall complication rates were 22% and 42% in the neurosurgery and endovascular groups, respectively (p = 0.084). Ischemic complication rates were 7.7% and 26% in the neurosurgery and endovascular groups, respectively (p = 0.037). Ischemic complications included 8 spinal infarctions, 2 brainstem infarctions, and 1 cerebellar infarction, which resulted in permanent neurological deficits. Mortality rates were 2.6% and 0% in the neurosurgery and endovascular groups, respectively (p > 0.99). Two patients died of systemic complications. The percentages of patients with improved modified Rankin Scale (mRS) scores were 60% and 37% in the neurosurgery and endovascular groups, respectively, with a median follow-up of 23 months (p = 0.043). Multivariate analysis identified endovascular treatment as an independent risk factor associated with retreatment (OR 54, 95% CI 9.9-300; p < 0.001). Independent risk factors associated with poor outcomes (a postoperative mRS score of 3 or greater) were a pretreatment mRS score of 3 or greater (OR 13, 95% CI 2.7-62; p = 0.001) and complications (OR 5.8; 95% CI 1.3-26; p = 0.020). Neurosurgical treatment was more effective and safer than endovascular treatment for patients with CCJ AVFs because of lower retreatment and ischemic complication rates and better outcomes.

Comparison of the incidence of depression before and after endovascular treatment in patients with lower limb peripheral artery disease.

Depression is a chronic illness that affects mood, physical health, and overall vitality and quality of life. Depression has been associated with an increased risk of all-cause and cardiovascular mortality among patients with peripheral arterial disease (PAD). Therefore, this study aimed to compare the incidence of depression before and after endovascular treatment in patients with lower limb PAD. This is an important clinical issue considering the worldwide increase in PAD with the aging population and the known negative impact of depression on recovery. This was a retrospective sub-analysis of data from the Tokyo Peripheral Vascular Intervention Study using the TOMA-CODE registry. The presence and extent of depressive symptoms were evaluated using the patient health questionnaire (PHQ-9), with a depressive tendency score of ≥ 5. The PHQ-9 score was evaluated before endovascular treatment (EVT) and at 4 (± 1) weeks after EVT. The study population consisted of 87 patients who completed the PHQ-9 before EVT, with 76 completing the post-EVT PHQ-9. Of these 76, 19 had a pre-EVT score ≥ 5. Overall, there was no difference in the pre- and post-EVT scores (P = 0.091). There was no significant change in the 19 patients with a pre-EVT score ≥ 5 (mean 9.2 ± 4.4); however, there was a tendency to improve in the pre- to post-EVT score (mean, 6.9 ± 5.2; P = 0.059). Diabetes was a significant negative factor for pre- to post-EVT score improvement (P = 0.023). Overall, symptoms of depression showed the tendency to improve at 30days post-EVT. However, diabetes was associated with lower improvement in symptoms.

Thrombus radiomics in patients with anterior circulation acute ischemic stroke undergoing endovascular treatment

BackgroundThrombus radiomics (TR) describe complex shape and textural thrombus imaging features. We aimed to study the relationship of TR extracted from non-contrast CT with procedural and functional outcome in endovascular-treated...

Reader Response: Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy.

We thank the authors for their contribution to an improved understanding of efficacy and complications of endovascular treatment (EVT) in patients with active malignancy.1 The findings of the study that patients with active cancer experienced worse outcomes after EVT, even with favorable prestroke function and technical success, is in agreement with data from the ESCAPE and ESCAPE-NA1 trials of EVT. In both these trials, we found that experiencing comorbid cancer was strongly associated with poor functional outcomes according to the modified Rankin scale score in patients at 90 days, despite achieving small final infarct volumes after EVT.2,3 While these data can help us adjust our expectations regarding post-EVT outcomes in patients with cancer, it remains challenging to identify a subset of these patients for whom EVT would be definitively futile, or even harmful, to justify withholding acute therapy—assuming they are otherwise eligible. In our clinical experience, we have found that treatment decisions become especially complex when the acute stroke evaluation unexpectedly uncovers a potential malignancy, such as an intracranial metastasis. Shared decision-making strategies have proven helpful in such settings, making the uncertain variables clear to the patient or their proxies.4

Editors' Note: Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy

In “Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy,” Verschoof et al. reported that despite similar technical success, patients with active cancer who underwent endovascular thrombectomy (EVT) experienced worse functional outcomes and a higher risk of mortality 90 days poststroke than patients without active cancer. Moores and Ganesh noted that these findings are consistent with results from the ESCAPE and ESCAPE-NA1 trials and it remains unclear how to identify patients who meet existing selection criteria for EVT but have no potential for benefit from EVT because they experience active cancer. They emphasized the importance of shared decision-making in these challenging situations, particularly when workup for acute stroke uncovers a new diagnosis of cancer. Verschoof et al. responded that the ESCAPE and ESCAPE-NA1 trials included 4 patients with cancer but did not comment on whether it was active. Because of the difficulty forming conclusions about the use of EVT in patients with active cancer through observational studies, they recommended the need for a controlled trial to study EVT in patients with active cancer. In “Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy,” Verschoof et al. reported that despite similar technical success, patients with active cancer who underwent endovascular thrombectomy (EVT) experienced worse functional outcomes and a higher risk of mortality 90 days poststroke than patients without active cancer. Moores and Ganesh noted that these findings are consistent with results from the ESCAPE and ESCAPE-NA1 trials and it remains unclear how to identify patients who meet existing selection criteria for EVT but have no potential for benefit from EVT because they experience active cancer. They emphasized the importance of shared decision-making in these challenging situations, particularly when workup for acute stroke uncovers a new diagnosis of cancer. Verschoof et al. responded that the ESCAPE and ESCAPE-NA1 trials included 4 patients with cancer but did not comment on whether it was active. Because of the difficulty forming conclusions about the use of EVT in patients with active cancer through observational studies, they recommended the need for a controlled trial to study EVT in patients with active cancer.

Author Response: Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy.

We thank Moores and Ganesh for their comments on our research1 and for drawing our attention to their 2 studies.2,3 Both these studies report on 4 patients with cancer, but do not state whether the cancer was active. It is difficult to obtain conclusive evidence from observational studies. We actually need an estimate of the interaction of cancer with treatment effect in a controlled trial. We also agree that when uncertainties remain, shared decision-making is essential. Hopefully, our studies will provide some needed insight into the treatment responses and outcomes of this challenging group of patients with active cancer.

Five-Year Outcomes After Endovascular Treatment for Large Vessel Occlusion Stroke.

BackgroundThe long-term outcomes of acute large vessel occlusion (LVO) in anterior circulation treated by endovascular treatment (EVT) remains to be determined. The aim of this study was to assess the 5-year outcomes of patients with LVO who underwent EVT.MethodsThis study was an observational, nationwide registry of consecutive patients with acute LVO who received EVT in 28 comprehensive stroke centers in China. The primary outcome was the proportion of favorable outcome [modified Rankin Scale score (mRS) 0–2] at 5 years. Secondary outcomes included proportions of patients with excellent outcome (mRS 0–1), all-cause mortality and risk of stroke recurrence at 5 years.ResultsA total of 807 patients were included into the study and had 90-day follow-up data, 657 patients had 5-year follow-up data. At 90 days, 218 patients (27.0%) had an excellent outcome, 349 patients (43.2%) had a favorable functional outcome. 199 patients (24.7%) died. At 5 years, 190 patients (28.9%) had an excellent outcome, 261 patients (39.7%) had a favorable functional outcome, 317 patients (48.2%) died and 129 (28.2%) had stroke recurrence. Because of missing 5-year follow-up data, among available 269 patients who achieved functional independence at 90 days, 208 (77.3%) maintained favorable outcome, 19 (7.1%) had disability (mRS 3–5) and 42 (15.6%) died at 5 years. Furthermore, among available 189 patients with mRS 3–5 at 90 days, 53 (28.0%) patients achieved favorable functional outcome, 60 (31.7%) patients maintained unfavorable functional outcome and 76 (40.2%) patients died within 5 years. Multivariate analyses identified that younger age [odds ratio (OR): 0.96; 95% CI, 0.93–0.99; P = 0.009], lower mRS at 90 days (OR: 0.15; 95% CI, 0.10–0.23; P < 0.001) and absence of stroke recurrence (OR: 0.001; 95% CI, 0.000–0.006; P < 0.001) were significantly associated with favorable outcome at 5 years. Advanced age (OR: 1.06, 95% CI, 1.04–1.08; P < 0.001), higher mRS at 90 days (OR: 0.84; 95% CI, 0.73–0.98; P = 0.021) and atrial fibrillation (OR: 1.63; 95% CI, 1.02–2.60; P = 0.04) were independent factors for stroke recurrence.ConclusionOur results indicated that the beneficial effect of EVT in patients with acute LVO can be sustained during the course of at least 5 years. Reducing the risk of stroke recurrence by anticoagulation for atrial fibrillation may be a crucial strategy to improve long-term outcome.

Endovascular Treatment Versus Best Medical Management in Acute Basilar Artery Occlusion Strokes: Results From the ATTENTION Multicenter Registry.

The authors compare the effectiveness and safety of endovascular treatment (EVT) versus best medical management (BMM) in strokes attributable to acute basilar artery occlusion (BAO). The present analysis was based on the ongoing, prospective, multicenter ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) trial registry in China. Our analytic sample comprised 2134 patients recruited at 48 sites between 2017 and 2021 and included 462 patients who received BMM and 1672 patients who received EVT. We performed an inversed probability of treatment weighting analysis. Qualifying patients had to present within 24 hours of estimated BAO. The primary clinical outcome was favorable functional outcome (modified Rankin Scale score, 0-3) at 90 days. We also performed a sensitivity analysis with the propensity score matching-based and the instrumental variable-based analysis. In our primary analysis using the inversed probability of treatment weighting-based analysis, there was a significantly higher rate of favorable outcome at 90 days among EVT patients compared with BMM-treated patients (adjusted relative risk, 1.42 [95% CI, 1.19-1.65]; absolute risk difference, 11.8% [95% CI, 6.9-16.7]). The mortality was significantly lower (adjusted relative risk, 0.78 [95% CI, 0.69-0.88]; absolute risk difference, -10.3% [95% CI, -15.8 to -4.9]) in patients undergoing EVT. Results were generally consistent across the secondary end points. Similar associations were seen in the propensity score matching-based and instrumental variable-based analysis. In this real-world study, EVT was associated with significantly better functional outcomes and survival at 90 days. Well-designed randomized studies comparing EVT with BMM in the acute BAO are needed. URL: www.chictr.org.cn; Unique identifier: ChiCTR2000041117.

Results of endovascular treatment of venous anastomotic stenosis in prosthetic arteriovenous for hemodialysis PTFE grafts. Comparative analysis between patent and occluded grafts

ObjectiveTo analyze the results of endovascular treatment of venous anastomotic stenosis (VAS) in humero-axillary arteriovenous grafts (HAG), comparing outcomes between patent and thrombosed HAG. Material and methodsA retrospective cohort study was made of endovascular treated patients because of a VAS in a HAG between January 2009 and December 2019. Group A: Thrombosed HAG secondary to a VAS. Group B: Patent HAG with a VAS detected during follow-up. Technical success was defined as residual stenosis after treatment <30%, and clinical success as satisfactory immediate dialysis after surgery. After ET a biannual clinical and ultrasound follow-up was performed. Statistical analysis: Survival analysis was performed for time-to-event data to assess patency. ResultsGroup A: 55 patients. Group B: 22. There were no significative differences in demographic and anatomical factors between groups.Technical and clinical success were 100% in group B and 94.5% and 91% respectively in group A.Primary patency at 1, 6 and 12 months was: Group A: 81.8%, 22.4% y 15.7% respectively. Group B: 100%, 85.9%, 76,4% (p < 0.001). Secondary patency at 1, 6 and 12 months was: Group A: 85.2%, 45.8% y 31.3% respectively. Group B 100%, 95.3%, 95.2% (p < 0.001). Use of non-covered stents was associated with an increased risk of occlusion (HR 2.669 IC 95% 1.146–6.216, p = 0.010). ConclusionA higher patency of EV performed on a patent HAG is expected. It is therefore advisable to develop surveillance programs that are capable to detect VAS before its occlusion.

Normobaric Hyperoxia Combined With Endovascular Treatment for Patients With Acute Ischemic Stroke: A Randomized Controlled Clinical Trial.

To investigate the safety and efficacy of normobaric hyperoxia (NBO) combined with endovascular treatment (EVT) in patients with acute ischemic stroke (AIS). In this single-center, proof-of-concept, assessor-blinded, randomized, controlled pilot study, patients with AIS in the acute anterior circulation with large vessel occlusion who had an indication for EVT were randomly assigned to the EVT group or the NBO + EVT group. The NBO + EVT group was given 100% oxygen through a face mask initiated before vascular recanalization (10L/min for 4 hours), while the EVT group was given room air. The primary endpoint was infarct volume measured by MRI within 24-48 hours after randomization. A total of 231 patients were screened, and 86 patients were randomized into a ratio of 1:1 (EVT group, n = 43; NBO + EVT group, n = 43). The median infarction volume of the NBO + EVT group at 24-48 hours after randomization was significantly smaller than that of the EVT group (median 20.1 vs 37.7 mL, p < 0.01). The median mRS score at 90 days was 2 for the NBO + EVT group when compared with 3 for the EVT group (adjusted value 1.8, 95% CI 1.3-4.2; p = 0.038). Compared with the EVT group, the NBO + EVT group had a lower incidence of symptomatic intracranial hemorrhagic (7% vs 12%), mortality (9% vs 16%), and adverse events (33% vs 42%); however, such a difference was not statistically significant. NBO in combination with EVT seems to be a safe and feasible treatment strategy that could significantly reduce infarct volume, improve short-term neurobehavioral test score, and enhance clinical outcomes at 90 days when compared with EVT alone in patients with AIS. These observations need to be further confirmed by a large, multicenter, randomized clinical trial. NCT03620370. This pilot study provides Class I evidence that NBO combined with standard EVT decreases infarction volume in patients with acute anterior circulation stroke.

The results of treatment of patients with tandem occlusions in the acute period of ischemic stroke

Objective – to evaluate the efficacy and safety of endovascular treatment in patients with acute ischemic stroke due to tandem occlusions.Materials and methods. The results of the examination and treatment of 237 patients with acute ischemic stroke due to large vessel occlusion who underwent endovascular reperfusion were analyzed. Tandem occlusions (internal carotid ‒ middle cerebral artery) were diagnosed in 65 (27.4 %) cases. Patient age ranged from 29 to 84 years (mean age ‒ 64.8 years). Men predominated among the patients (46 (70.8 %)). Among patients with ischemic stroke due to tandem occlusion, 29 (44.6 %) were diagnosed with atherothrombotic stroke subtype, 27 (41.5 %) had cardioembolic. In 9 (13.9 %) cases the cause of thrombosis was spontaneous dissection of the wall of the internal carotid artery. To assess collateral blood flow, the ACG scale proposed by the American Society for Interventional and Therapeutic Radiology was used. The quality of reperfusion was assessed using the eTICI scale. Analysis of the functional results of patients after 90 days from the onset of the disease was carried out according to the modified Rankine scale (mSR).Results. According to our study, a good angiographic result (eTICI 2b-3) was achieved in 54 (83.1 %) patients. Intraoperative complications were registered in 8 (12.3 %) cases. An analysis of the dependence of the quality of reperfusion on the severity of collateral compensation of a thrombosed artery showed that in patients with developed (ACG 3-4) collaterals (35 (53.8 %)) good reperfusion was achieved in 33 (94.3 %) cases, in patients with mild (ACG 0-2) collateral compensation (30 (46.2 %)) the quality of eTICI 2b-3 reperfusion was achieved only in 21 (70.0 %) cases. It was found that out of 40 (61.5 %) patients with tandem occlusion, in whom arterial puncture was performed within 6 hours after the onset of neurological symptoms, 15 (37.5 %) had 0-2 points for mSR after 90 days. When puncturing the artery later than 6 hours (25 (38.5 %) cases), a good result after 90 days was registered only in 7 (28.0 %) patients. Analysis of the influence of collaterals on the dynamics of changes according to multislice computed tomography revealed that patients with well-defined collaterals (35 (53.8 %) cases) during the control examination had ASPECTS scores from 1 to 9 points (average ‒ 5.3 points). Patients with mild collaterals (30 (46.2 %) observations)) on the ASPECTS scale during the control examination had from 0 to 6 points (average ‒ 2.2 points). During the first day or at the time of discharge, a statistically significant decrease in neurological deficit was observed in the group with successful restoration of cerebral blood flow findings.Conclusions. Many factors influence the clinical efficacy of endovascular reperfusion techniques: hypoperfusion area and area of brain damage according to computed tomography during hospitalization, quality of endovascular reperfusion, time from the onset of the disease, collateral compensation of the thrombosed artery basin, complications during surgery. Well-defined collaterals are a predictor of positive dynamics after successful endovascular reperfusion.

Experience of using stent grafts in the treatment of patients with arrosive bleeding after pancreatic surgery

Aim. To evaluate inhospital outcomes of endovascular treatment in patients who underwent endoprosthetic replacement of the culprit vessel due to arrosive bleeding after pancreatic surgery.Material and methods. In the period 2012-2021 at the A. V. Vishnevsky National Medical Research Center of Surgery, 821 operations on the pancreas due to tumors and complicated chronic pancreatitis were performed. Seventy-five (9,1%) patients developed postoperative arrosive bleeding. Stent grafts were used to stop bleeding in 14 (18,7%) of them. There were 9 men (64,3%) and 5 women (35,7%). The median age of patients was 60 years (men — 61 years, women — 59 years). Arrosive bleeding occurred after pancreaticoduodenal resection in 13 patients, while in one case — after distal pancreatic resection. In all 14 cases, postoperative bleeding was severe and classified as grade C according to the International Study Group for Pancreatic Surgery (ISGPS) classification.Results. There were following sources of bleeding: gastroduodenal artery — 4 (28,6%) patients, proximal hepatic arteries (right/left) — in 4 (28,6%) patients, proximal superior mesenteric artery — in 2 (14,3%), dorsal pancreatic artery — in 1 (7,1%), false aneurysm of proximal splenic artery — in 1 (7,1%), proximal common hepatic artery — in 2 (14,3%). In 10 (71,4%) patients, endoprosthetic replacement of the proximal segment of culprit artery was performed, while in 4 (28,6%) patients with arrosion of short gastroduodenal artery stump and false aneurysm, endoprosthesis replacement of the common hepatic artery was performed with a transition to the proper hepatic artery. The technical success of endovascular hemostasis (absence of contrast media extravasation) was achieved in 100% of cases. Three (21,4%) of 14 patients developed rebleeding from another arterial source. Inhospital mortality was 28,6% (n=4). The cause of deaths in 3 cases was the direct complications of endovascular hemostasis, while in one patient — progressive postoperative pancreatitis with the outcome in multiple organ failure.Conclusion. Endovascular hemostasis using a stent graft is an effective surgical method for the treatment of arrosive bleeding after pancreatic surgery. The intervention is associated with possible complications, the risk of which must be taken into account before the procedure. We consider arrosive bleeding from a defect in the main vessel (common/ proper/right or left hepatic arteries, superior mesenteric artery) as an indication for performing endoprosthetic replacement.

Endovascular treatment in patients with acute ischemic stroke and cancer: Systematic review and meta-analysis

Introduction: Although stroke occurs frequently in patients with cancer, there is scarce evidence regarding the safety and efficacy of endovascular treatment (EVT) in patients with acute ischemic stroke and concurrent cancer. We performed a systematic review and meta-analysis to summarize the existing literature. Methods: We searched for English written observational studies reporting data on safety and efficacy of EVT in patients with acute ischemic stroke and concurrent cancer. Outcomes of interest were: functional independence (modified Rankin Scale (mRS) ⩽ 2); mortality at 3 months; rate of successful recanalization (modified Treatment In Cerebral Ischemia (mTICI) 2b or 3); occurrence of any hemorrhagic transformation (both symptomatic and asymptomatic). We pooled data with Maentel-Haenszel model to calculate cumulative odds ratios (ORs). Results: We included seven studies with a total of 4465 patients, of whom 262 (6%) with cancer. We observed various definitions of cancer across included studies. Patients with cancer had less likely mRS⩽2 at 3 months (24% vs 42%, OR = 0.44; 95% CI = 0.32–0.60) and increased probability of death (43% vs 19%, OR = 5.02; 95% CI = 2.90–8.69). There was no difference in successful recanalization (70% vs 75%, OR = 0.84; 95% CI = 0.49–1.44); patients with cancer had increased risk of any intracerebral hemorrhage after treatment (49% vs 34%, OR = 1.95; 95% CI = 1.28–2.96), though not for symptomatic ICH (OR 1.04; 95% CI = 0.59–1.85). Conclusion: Patients with acute ischemic stroke and cancer have similar EVT recanalization but higher probability of functional dependence, death, and any hemorrhagic transformation, though not necessarily symptomatic, compared with patients without cancer. Our results may help communication with patients and carers.

Endovascular treatment for wake-up stroke and daytime unwitnessed stroke: A meta-analysis

BackgroundEvidence from sources outside the typical clinical research setting, such as a real-world setting, may complement evidence from randomised controlled trials (RCTs). The aim of the present study was to carry out a meta-analysis of available real-world evidence that focused on the efficacy and safety of endovascular treatment in patients with wake-up stroke (WUS) or daytime unwitnessed stroke (DUS) compared to that in patients treated ≤ 6 h after the onset of an ischemic stroke. MethodsData mining was conducted on 1 May 2021 from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials Cochrane Library. The study reviewed all published that assessed the effect of endovascular treatment in WUS and DUS compared to that received by patients with ischemic stroke. Relevant data were extracted and the narrative was reviewed and analysed. The results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). FindingsThe meta-analysis showed no significant differences between the two groups in the rates of functional independence (OR, 0.81; 95% CI, 0.65–1.02; P = 0.07), symptomatic intracerebral haemorrhage (OR, 0.86; 95% CI, 0.57–1.30; P = 0.470), and all-cause mortality (OR, 0.92; 95% CI, 0.73–1.16; P = 0.50). There was also no heterogeneity between the trials. ConclusionThe pooled analysis provided evidence to support the use of endovascular treatment in WUS and DUS with favourable perfusion imaging. The meta-analysis confirmed the main findings of RCTs of endovascular treatment in WUS and DUS in a real-world setting and therefore strengthens the validity of this treatment strategy.

Endovascular treatment for acute basilar artery occlusion due to different stroke etiologies of large artery atherosclerosis and cardioembolism.

Stroke etiology may affect the prognosis of acute basilar artery occlusion (BAO). This study aimed to estimate the efficacy and safety of endovascular treatment (EVT) in BAO strokes due to the underlying stroke etiologies of large artery atherosclerosis (LAA) and cardioembolism (CE). Patients with LAA and CE subtypes from the registry EVT for Acute Basilar Artery Occlusion Study (BASILAR) were selected for this analysis. We estimated the EVT treatment effect relative to standard medical treatment (SMT) in these patients by using a propensity score approach with inverse probability of treatment weighted estimation. Outcomes included 90-day favorable functional outcomes (modified Rankin scale (mRS) 0-3), functional independence (mRS 0-2), all-cause mortality, and symptomatic intracranial hemorrhage (sICH). A total of 744 patients were included in the final analysis. After weighting with inverse probability of treatment estimation, the patients who, based on their characteristics, were treated with EVT rather than SMT, demonstrated higher rates of favorable functional outcomes in both the LAA (29.2% vs 11.7%, adjusted OR with 95% CI: 4.34 [2.15-8.78], p < 0.001) and the CE subtype (36.0% vs 8.1%, adjusted OR with 95% CI: 9.14 [1.96-42.55], p = 0.005). A similar finding was also observed for functional independence. EVT patients also demonstrated lower rates of mortality than SMT. Among EVT patients, no significant difference was observed in mortality or sICH between LAA and CE groups, but LAA patients had lower rates of favorable functional outcome and functional independence (29.2% vs 37% and 24.2% vs 32.9%, respectively), where the latter remained significant after adjustment for imbalances in baseline data (p = 0.04). In acute BAO strokes, both LAA and CE patients who, based on their characteristics, were treated with EVT rather than SMT, demonstrated better outcomes. Among EVT patients, LAA and CE subtypes displayed important baseline and treatment differences, and LAA patients were less likely to achieve functional independence at 3 months, but mortality and sICH were similar between LAA or CE subtypes. These results need to be confirmed in future clinical trials.

Risk Factors of Futile Recanalization Following Endovascular Treatment in Patients With Large‐Vessel Occlusion: Systematic Review and Meta‐Analysis

Background Although successful recanalization (modified Thrombolysis in Cerebral Infarction score 2b–3) can be achieved in &gt;80% of patients experiencing stroke attributable to large‐vessel occlusion, up to 50% of patients may develop poor clinical outcomes (modified Rankin scale score at 90 days of 3–6), termed as futile recanalization (FR). The meta‐analysis aims to determine various risk factors associated with FR. Methods In February 2021, a comprehensive literature search on risk factors associated with FR was performed with keywords, including “stroke,” “thrombectomy,” “treatment outcome,” and “risk factors.” Their correlations with FR were evaluated using the random effect size meta‐analysis model. Results Twenty studies with 3037 patients were included with an FR rate of 51.0%. Our meta‐analyses showed that age (mean difference [MD], 5.6; 95% CI, 4.7–6.6), National Institutes of Health Stroke Scale score (MD, 4.2; 95% CI, 3.2–5.1), Alberta Stroke Program Early Computed Tomography (CT) Score (MD, −0.5; 95% CI, 0.8–0.3), hypertension (odds ratio [OR], 1.5; 95% CI, 1.3–1.9), systolic blood pressure (MD, 6.9; 95% CI, 3.6–8.7), atrial fibrillation (OR, 1.5; 95% CI, 1.2–1.8), IV tPA (tissue‐type plasminogen activator) (OR, 0.7; 95% CI, 0.5–0.8), puncture to recanalization time (MD, 9.6; 95% CI, 5.3–13.8), and time of onset to recanalization (MD, 32.1; 95% CI, 6.5–47.7) were significantly associated with FR ( P &lt;0.001). Conclusions Age, admission National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, comorbidities, including hypertension, systolic blood pressure, atrial fibrillation, and use of IV tPA, as well as time frames, including onset to recanalization and onset to arrival, were significant influencing factors for FR after mechanical thrombectomy. Future research on the mechanism underlying FR is warranted.

Preintervention Computed Tomography Improves the Performance of Endovascular Intervention in Patients with Abdominopelvic Trauma

PurposeTo evaluate the role of computed tomography (CT) and CT angiography in guiding endovascular arteriography (EA) and embolization in hemodynamically (HD) stable and unstable patients with abdominal and/or pelvic (AP) trauma. Materials and MethodsA retrospective review was performed of patients with AP trauma who underwent EA with or without embolization (from January 2012 to August 2020) at an urban, level I trauma center. Patients aged <18 years or those undergoing EA outside of the abdomen and/or pelvis were excluded. Demographics, imaging findings, procedure length, contrast agent administration, laboratory values, and outcomes were compared on the basis of preprocedural imaging technique and hemodynamic status. ResultsA total of 190 patients with AP trauma underwent EA with or without embolization; among them, 123 were HD stable and underwent CT/CT angiography, whereas 67 were initially HD unstable and underwent operative management prior to EA. Of these patients, 38 underwent CT/CT angiography after hemodynamic stability was achieved prior to postoperative EA. The incidence of therapeutic embolization for arterial injury on EA was significantly higher in patients with preprocedural CT/CT angiography (65.8% vs 44.8%, P = .04). The positive and negative predictive values of CT angiography for arterial injury at the time of EA were 92.3% and 100%, respectively. Prior imaging was associated with a reduced contrast agent requirement at the time of EA and reduced transfusion requirement (P = .05 and P = .02). No significant differences were observed in adverse outcomes for patients undergoing preprocedural imaging. ConclusionsCT or CT angiography prior to EA for HD stable and unstable patients with AP trauma may improve the likelihood of therapeutic embolization and enable improved procedure metrics without increasing adverse outcomes.

Patients Undergoing Bypass for Infrapopliteal Chronic Limb-Threatening Ischemia Have Better 2-Year Outcomes Than Those Undergoing Endovascular Peripheral Vascular Interventions

Endovascular interventions (peripheral vascular interventions [PVI]) have become first-line in patients with infrapopliteal chronic limb-threatening ischemia (IP-CLTI). We analyzed the outcomes of lower extremity bypass (LEB) to tibial targets compared with PVI in patients with infrapopliteal targets for CLTI (IP-CLTI) as the initial treatment. We queried the Vascular Quality Initiative LEB and PVI databases from 2003 to 2021 to identify elective tibial LEB or PVI in patients with IP-CLTI. All patients with prior ipsilateral lower extremity interventions (PVI/LEB), emergent interventions, or interventions for claudication were excluded. Primary outcomes were primary patency, major adverse limb events (MALE) defined as vascular reintervention or above-ankle amputation, and amputation-free survival at 2 years. Standard statistical methods were used. We identified 24,806 procedures (18,198 PVI, 6608 LEB). The use of PVI has increased over time in the cohort from 49.7% in 2010 to 82.25% in 2021 (P < .001). Patients who underwent PVI were older, less frequently male, and had more comorbid conditions. Patients undergoing PVI were more likely to present with Rutherford class 5/6 ischemia compared with LEB (Table). Among PVI cases, 46% (8330) were isolated tibial interventions, the remainder involved multiple levels. Although 85% (5574) of LEB were to tibial targets with the remainder involving pedal or plantar targets. LEB had statistically significantly higher rates of postoperative morbidity in terms of major adverse cardiac events. Although postoperative mortality at 30 days was low in both groups but was significantly higher in the PVI cohort (1.77% PVI; 1.07% LEB; P < .001) (Table). On unadjusted Kaplan-Meier survival analysis, the LEB group had a significantly higher primary patency at 2 years (52% ± 2.04% LEB vs 34.13% ± 1.6% PVI; P = .011) compared with the PVI group, a similar pattern was seen for freedom from MALE at 2 years (40.44% ± 1.9% LEB vs 27.39% ± 1.37% PVI; P = .03) (Table). LEB had a significantly higher amputation-free survival at 2 years (73.7% ± 0.5% LEB vs 64.61% ± 0.38% PVI; P < .001) compared with PVI (Figure). In an adjusted Cox regression model (adjusted for comorbidities and Rutherford class), PVI was independently associated with loss of primary patency (hazard ratio [HR], 1.1; 95% confidence interval [CI], 1.03-1.11; P = .006) and increased risk of amputation or death (HR, 1.25; 95% CI, 1.17-1.33; P < .001), but it was not significantly associated with MALE (HR, 1.04; 95% CI, 0.98-1.11; P = .238) (Table). Surgical bypass outcomes are superior to endovascular intervention in patients with IP-CLTI. In medically and anatomically appropriate candidates, LEB should be considered first line even in the endovascular era.TableDemographics and outcomes of endovascular interventions compared with surgical bypassEndovascular (n = 18,198)Bypass (n = 6606)P valueDemographics Age, years71.0 ± 12.169.00 ± 11.27<.001 Male sex11,880 (65.28)4783 (72.4)<.001 White11,702 (64.33)4711 (71.29)<.001 History of diabetes13,616 (74.84)4005 (60.63)<.001 History of coronary artery disease6040 (33.21)2082 (31.55).014 Prior coronary artery bypass grafting3796 (22.18)1286 (23.22)>.05 Prior PCI3709 (21.68)1131 (20.43).048 History of congestive heart failure5190 (28.53)1444 (21.86)<.001 History of chronic obstructive pulmonary disease3409 (18.74)1427 (21.6)<.001 History of hypertension16,400 (90.52)5943 (90.2)>.05 On dialysis3351 (18.42)621 (9.4)<.001 Current/former smoker10,172 (55.98)4890 (74.05)<.001 Obese6449 (35.44)1916 (29)<.001 Rutherford class 5/6 ischemia (tissue loss)15,523 (85.3)4756 (71.97)<.001Type of InterventionNA Unknown249 (1.38)0 (0) Plain balloon angioplasty11,953 (66.4)0 (0) Atherectomy2773 (15.4)0 (0) ther balloon angioplasty1727 (9.59)0 (0) Stn1300 (7.22)0 (0) Bypass0 (0)6608 (100)Postoperative outcomes Major adverse cardiac events166 (1.4)577 (9.52)<.001 Postoperative myocardial infarction53 (0.45)239 (3.62)<.001 Postprocedure pulmonary complication69 (0.58)110 (1.67)<.001 In-hospital mortality80 (0.44)16 (0.24).027 30-Day mortality323 (1.77)71 (1.07)<.001Kaplan-Meier survival analysis at 2 years Primary patency, % ± SEM %34.13% ± 1.6%52% ± 2.04%.011 Freedom from MALE27.39% ± 1.37%40.44% ± 1.9%.03Amputation-free survival64.61% ± 0.38%73.7% ± 0.5%<.001Adjusted Cox proportional hazard models at 2 years Primary patency1.1 [1.03-1.11]ref.006 MALE1.04 [0.98-1.11]ref.238Amputation-free survival1.25 [1.17-1.33]ref<.001MALE, Major adverse limb events; PCI, percutaneous coronary in intervention; SEM, standard error of the mean.Values are mean ± standard deviation or number (%) unless otherwise indicated. Open table in a new tab

Single-Stage Endovascular Treatment of Severe Cranial Artery Stenosis Coexisted With Ipsilateral Distal Tandem Intracranial Aneurysm.

ObjectiveThe coexistence of severe cranial artery stenosis and ipsilateral distal tandem intracranial aneurysm is an unusual phenomenon. Currently, there is no consensus to provide treatment guidelines for concomitant lesions. This study aims to evaluate the safety and effectiveness of single-stage endovascular treatment in patients under this special condition.MethodsWe illustrated a case series of 10 patients with the coexistence of severe cranial artery stenosis and ipsilateral distal tandem intracranial aneurysm in our hospital. And a systematic PubMed search of English-language literature published between 1990 and 2021 was carried out using the keywords: “(carotid OR vertebral OR subclavian artery stenosis) AND (aneurysm) AND (coincident OR coexist OR concomitant OR simultaneous OR ipsilateral).” Clinical information, including age, gender of the patients, as well as symptoms (artery stenosis or aneurysm), localization of artery stenosis and aneurysm, treatment, and outcome, were collected and analyzed.ResultsIn the majority of the patients, symptoms were attributed to severe artery stenosis, and the coexisted lesions were located in the anterior circulation system. Most patients achieved an excellent clinical outcome, and no death was observed. No differences were found in a prognosis between single-stage or multiple-stage endovascular treatment.ConclusionsA single-stage endovascular procedure is technically feasible and effective to treat the coexistence of severe cranial artery stenosis and ipsilateral distal tandem intracranial aneurysm in the anterior circulation as well as in the posterior circulation.