Rate Of Hemorrhagic Complications Research Articles

Safety of dual antiplatelet therapy in the acute phase of aneurysmal subarachnoid hemorrhage: a propensity score-matched study.

With the evolution of neuroendovascular treatments, there is a great trend to treat acutely ruptured wide-necked aneurysms with stent-assisted coiling (SAC) and flow diverters (FDs), which inevitably requires dual antiplatelet therapy (DAPT). This therapy can increase the rate of hemorrhagic complications following other neurosurgical maneuvers, such as external ventricular drain (EVD) placement or removal. In this study, the authors aimed to evaluate the safety of DAPT in patients with aneurysmal subarachnoid hemorrhage (SAH) treated with SAC or FDs and the therapy's potential benefit in reducing cerebral ischemia and cerebral vasospasm. In this retrospective study, the authors reviewed the records of patients who had been admitted to their hospital with acute aneurysmal SAH and treated with SAC, FDs, and/or coiling between 2012 and 2022. Patients were classified into two groups: a DAPT group, including patients who had received DAPT for SAC or FDs, and a non-DAPT group, including patients who had not received any antiplatelet regimen and had been treated with coiling. Perioperative hemorrhagic and ischemic complications and clinical outcomes were compared between the two groups. From among 938 cases of acute ruptured aneurysms treated during 10 years of study, 192 patients were included in this analysis, with 96 patients in each treatment group, after propensity score matching. All basic clinical and imaging characteristics were equivalent between the two groups except for the neck size of aneurysms (p < 0.001). EVD-related hemorrhage was significantly higher in the DAPT group than in the non-DAPT group (p = 0.035). In most patients, however, the EVD-related hemorrhage was insignificant. Parent artery or stent-induced thrombosis was higher in the DAPT group than in the non-DAPT group (p = 0.003). The rate of cerebral ischemia was slightly lower in the DAPT group than in the non-DAPT group (11.5% vs 15.6%, p = 0.399). In the multivariate analysis, cerebral ischemia, rebleeding before securing the aneurysm, extracranial hemorrhage, and cerebral vasospasm were the predictive factors of a poor clinical outcome (p < 0.001, p < 0.001, p = 0.038, and p = 0.038, respectively). The DAPT regimen may be safe in the setting of acute aneurysmal SAH. Although EVD-related hemorrhage is more common in the DAPT group than the non-DAPT group, it is usually insignificant without any neurological deficit.

Comparison of intraoperative blood loss and perioperative complications between preoperative embolization and nonembolization combined with spinal tumor surgeries: a systematic review and meta-analysis.

The present study aimed to comparatively evaluate intraoperative blood loss (IBL) and perioperative complications between preoperative embolization (PE) and nonembolization (NE) combined with spinal tumor surgeries as well as to determine the subgroup of spinal tumor surgeries suitable for PE. A systematic search in PubMed and EMBASE and an additional search by reference lists of the retrieved studies were undertaken by two reviewers. The mean IBL and perioperative complication rate were employed as the effect size in the general quantitative synthesis through direct calculation. Meta-analysis was performed using standardized mean difference (SMD) and weighted mean difference (WMD) of IBL and the odds ratio (OR) of complications. Heterogeneity was assessed using the I2 statistic. The reviewers selected 17 published studies for the general quantitative synthesis and meta-analyses. The mean IBL of spinal tumor surgeries was 1786.3mL in the NE group and 1716.4mL in the PE group. The mean IBL between the two groups was similar. The pooled WMD and SMD of IBL in spinal tumor surgeries was 324.15mL (95% CI 89.50-1640.9, p = 0.007) and 0.398 (95% CI 0.114-0.682, p = 0.006), respectively. The reduction of the PE group compared with the NE group for the rates of major complications and major hemorrhagic complications were 7.80% and 5.71%, respectively. The risk of PE-related complications in the PE group was only 1.53% more than in the PE group. The pooled OR of major complications in spinal tumor surgeries was 1.426 (95% CI 0.760-2.674; p = 0.269). PE may be suitable for spinal tumor surgeries and some subgroups. From the perspective of complications, PE may also be a feasible option for spinal tumor surgeries.

Efficacy of the Hepcon system in reducing hemorrhagic and thrombotic complications in antiphospholipid syndrome patients undergoing cardiac surgery.

Patients with Antiphospholipid Syndrome (APS) undergoing cardiopulmonary bypass (CPB) surgery are at increased risk for thrombotic and hemorrhagic complications. Anticoagulation during CPB is typically monitored with activated clotting time (ACT) which may be falsely prolonged in patients with APS. The Hepcon Hemostasis Management System quantitatively determines the whole blood heparin concentration through heparin/protamine titration. This was a retrospective study of APS patients who underwent cardiac surgery requiring CPB at the Cleveland Clinic between April 2013, and July 2020. The primary endpoint was the composite rate of hemorrhagic or thromboembolic complications per surgical case in patients monitored by Hepcon versus patients monitored by ACT. Secondary endpoints were median volume of chest tube output and packed red blood cell (PRBC) transfusion within the first three post-operative days. 43 patients were included. 20 (47%) patients were monitored using Hepcon while 23 (53%) were monitored using ACT. For the primary endpoint of rate of thromboembolic or hemorrhagic complications per surgical case, there was no statistically significant difference between the Hepcon and ACT groups (HMS, 6/20 [30%]; ACT, 7/23 [30%]; p = >0.99). For the secondary endpoints, there was no statistically significant difference in median post-operative chest tube output (780mL vs. 850mL; p = 0.88) and median post-operative PRBC transfusion (1 unit vs. 0 unit; p = 0.28) between the Hepcon and ACT groups, respectively. There was no difference in the composite outcome of thrombotic or hemorrhagic complications in patients monitored by Hepcon versus those monitored by ACT.

Endovascular treatment outcomes of vertebrobasilar junction aneurysms: Systematic review and meta-analysis.

Vertebrobasilar junction (VBJ) aneurysms represent a relatively rare and often anatomically complex subgroup of saccular aneurysms. This systematic review and meta-analysis aimed to assess the safety and efficacy of endovascular treatment (EVT) of VBJ aneurysms. PubMed, Web of Science, Ovid Medline, Ovid Embase, and Scopus were searched from inception to 20 December 2022. We included primary studies assessing the long-term clinical and angiographic outcomes for VBJ aneurysms treated with endovascular techniques. We excluded surgically managed studies. All data were analyzed using R software version 4.2.1. We calculated pooled prevalence rates and their corresponding 95% confidence intervals (CI). In this meta-analysis, a total of 76 VBJ aneurysms from seven studies were included for quantitative analysis. The results showed that the rate of adequate occlusion (complete + near complete occlusion) was 94.1% (95% CI = 76.71-98.71), and the rate of complete occlusion was 77.7% (95% CI = 63.07-87.65). A modified Rankin Scale (mRS) score of 0-2 was achieved in 93.9% of patients (95% CI = 67.65-99.14). The mortality rate was found to be 5.9% (95% CI = 0.97-28.55), and the retreatment rate was 4.6% (95% CI = 1.50-13.36). The overall ischemic complication rate was 4.7% (95% CI = 0.73-25.4), while the overall hemorrhagic complication rate was 4.6% (95% CI = 1.5-13.36). The treatment of VBJ aneurysms with EVT is effective in achieving curative treatment and is associated with good clinical outcomes and low mortality rates. These findings provide important insights into the clinical and angiographic outcomes and the complication rates of EVT for VBJ aneurysms.

Impact of branch arteries on efficacy of endoluminal flow diverters: Insights from posterior communicating artery aneurysms.

Flow diverter treatment may inevitably require jailing of the branch vessels. While the patency of covered branch arteries and associated safety risks have been a topic of substantial interest, the question of whether the characteristics of branch vessels affect flow diversion's efficacy remains unanswered. In this study, we aimed to assess the impact of branch arteries on the efficacy of endoluminal flow diverters, specifically focusing on posterior communicating artery (Pcomm) aneurysms. Following PRISMA guidelines, we systematically searched the MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane databases with predefined keywords. Studies providing data for flow diversion outcomes in Pcomm aneurysms were included. Outcomes of interest included complete and adequate aneurysm obliteration, ischemic and hemorrhagic complications, and Pcomm occlusion in the follow-up period. A random or fixed effects model was used to calculate the odds ratios (ORs) and pooled event rates with their corresponding confidence intervals (CI). The overall complete and adequate aneurysm occlusion rates were 72.25% (95% CI: 64.46-78.88%) and 88.37% (95% CI: 84.33-92.6), respectively. Fetal-type Pcomm aneurysms had significantly lower complete aneurysm occlusion rates than the nonfetal-type Pcomm aneurysms (OR: 0.12, 95% CI: 0.05-0.29). Overall ischemic and hemorrhagic complication rates were 2.62% (95% CI = 0.71-5.32) and 0.71% (95% CI: 0-2.24), respectively. There were no significant associations between Pcomm morphology and complications (OR: 3.61, 95% CI = 0.42-31.06 for ischemic complications and OR: 2.31, 95% CI = 0.36-14.6 for hemorrhage). Overall Pcomm occlusion rate was 32.04% (95% CI = 19.96-47.13), and the Pcomm patency was significantly lower in nonfetal-type Pcomm aneurysms (OR: 0.10, 95% CI = 0.02-0.44). Our meta-analysis suggests that flow diversion is a safe treatment option for Pcomm aneurysms, regardless of fetal-type Pcomm morphology. However, on the other hand, our findings indicate that Pcomm anatomy or the presence of jailed large branches can affect the efficacy of flow diverter treatment.

Endovascular treatment of acute basilar artery occlusion: A systematic review and meta-analysis of first-line stent retriever versus direct aspiration.

The best choice between first-line aspiration and stent retriever for acute basilar artery occlusion remains controversial. This study aims to perform a systematic review and meta-analysis comparing the stent retriever and direct aspiration about reported recanalization rates and periprocedural complications. PubMed, Embase, Web of Science, Cochrane, and Clinical Trials were searched for the studies evaluating the efficacy and safety of first-line aspiration versus stent retriever for acute basilar artery occlusion. A standard software program (Stata Corporation) was used for end-point analyses. Statistical significance was defined as a p-value less than .05. A total of 11 studies were involved in the current study, including 1014 patients. Regarding postoperative recanalization, the pooled analysis identified a significant difference in successful recanalization (odds ratio [OR]=1.642; 95% confidence interval (95% CI): 1.099-2.453; p=.015) and complete recanalization (OR=3.525; 95% CI: 1.306-2.872; p=.001) between the two groups in favor of the first-line aspiration. Concerning the complications, the first-line aspiration could achieve a lower rate of total complication (OR=.359; 95% CI: .229-.563; p<.001) and hemorrhagic complication (OR=.446, 95% CI: .259-.769; p=.004) than stent retriever. No significant difference was observed in postoperative mortality (OR=.966; p=.880), subarachnoid hematoma (OR=.171; p=.094), and parenchymal hematoma (OR=.799; p=.720). In addition, the pooled results revealed a significant difference in procedure duration between the two groups in favor of aspiration (WMD=-27.630, 95% CI: -50.958 to -4.302; p=.020). However, there was no significant difference in favorable outcome (OR=1.149; p=.352) and rescue therapy (OR=1.440; p=.409) between the two groups. Given that the first-line aspiration was associated with a higher rate of postoperative recanalization, a lower risk of postoperative complication, and a faster duration of the procedure, these findings support the aspiration may be more secure than a stent retriever.

Transoral Laser Microsurgery versus Robot-Assisted Surgery for Squamous Cell Carcinoma of the Tongue Base (Oncological and Functional Results)-A Retrospective GETTEC Multicenter Study.

The base of the tongue (BOT) is the second most common site for squamous cell carcinoma (SCC) in the oropharynx. There are currently no clear guidelines for the management of BOT SCC. Our main objective was to compare the oncological outcomes of two minimally invasive approaches, transoral laser microsurgery (TLM) and transoral robot-assisted surgery (TORS). This was a retrospective French GETTEC (Groupe d'Études des Tumeurs de la Tête et du Cou) multicenter study of patients with BOT SCC removed surgically either by TLM or TORS between 2005 and 2021. The study group included 16 patients treated by TLM and 38 by TORS, with median follow-up times of 14.4 and 37.2 months, respectively. The overall survival (OS) rates at 2 and 3 years were 67% in the TLM group and 90% at 2 years and 86% at 3 years in the TORS group (p = 0.42, p = 0.20). There was no significant difference in recurrence-free survival (RFS) between the two techniques after 2 and 3 years. The tumors removed by TORS were significantly larger. Operative times were significantly shorter in the TLM group. There were no differences in feeding resumption; none of the patients in the TLM group required a tracheotomy. Postoperative hemorrhagic complication rates were similar in the two groups (12% for TLM and 13% for TORS). Both TORS and TLM showed encouraging oncological, functional, and safety results in BOT SCC even in recurrence or second primary cancer patients, without a technique being found superior in terms of OS or RFS. Tumors removed by TORS were larger without an increase in postoperative bleeding, extending the possibilities of transoral treatment.

Endovascular treatment of multiple intracranial aneurysms in patients with subarachnoid hemorrhage: one or multiple sessions?

This study aimed to compare the safety and efficacy of single- and multiple-stage endovascular treatment in aneurysmal subarachnoid hemorrhage (SAH) patients with multiple intracranial aneurysms. We retrospectively analyzed the clinical and imaging data of 61 patients who harbored multiple aneurysms and presented to our institution with aneurysmal subarachnoid hemorrhage. Patients were grouped according to endovascular treatment strategy: one-stage or multiple-stage. The 61 study patients harbored 136 aneurysms. One aneurysm in each patient had ruptured. In the one-stage treatment group, all 66 aneurysms in 31 patients were treated in one session. The mean follow-up was 25.8 months (range, 12-47). At the last follow-up, the modified Rankin scale was ≤2 in 27 patients. In total, 10 complications occurred (cerebral vasospasm, six patients; cerebral hemorrhage, two patients; and thromboembolism, two patients). In the multiple-stage treatment group, only the ruptured aneurysm (30 in total) was treated at the time of presentation, and the remaining aneurysms (40 in total) were treated later. The mean follow-up was 26.3 months (range, 7-49). At the last follow-up, the modified Rankin scale score was ≤2 in 28 patients. In total, five complications occurred (cerebral vasospasm, four patients; and subarachnoid hemorrhage, one patient). During the follow-up period, there was one recurrence of aneurysm with subarachnoid hemorrhage in the single-stage treatment group and four recurrences in the multiple-stage treatment group. Both single- and multiple-stage endovascular treatment is safe and effective in aneurysmal subarachnoid hemorrhage patients who harbor multiple aneurysms. However, multiple-stage treatment is associated with a lower rate of hemorrhagic and ischemic complications.

Venous thromboembolism after spontaneous intracerebral hemorrhage and the status quo of anticoagulation in this population: A retrospective case[sbnd]control study from a tertiary hospital in China

ObjectivePatients with spontaneous intracerebral hemorrhage (sICH) are susceptible to venous thromboembolism (VTE) including pulmonary embolism (PE) and deep venous thrombosis (DVT) due to a variety of risk factors. There are few studies regarding the predictive value of D-dimer for VTE in patients with sICH, and the anticoagulation therapy for these patients are still controversial. The objective of this study is to study the independent predictors of VTE in sICH patients. The rates of anticoagulation therapy and hemorrhagic evens were also investigated. MethodsRetrospective review of patients with sICH admitted to the First Affiliated Hospital of Dalian Medical University from 2012 to 2022 and who developed VTE (PE and/or DVT) during hospitalization. A similar number of sICH patients without VTE were randomly selected into the control group. A variety of clinical characteristics were compared between groups. Univariate and multivariate analyses were performed to identify independent predictors of VTE in patients with sICH. ResultsA total of 270 sICH patients were enrolled in this study, including 132 patients with VTE and 138 patients without VTE. After adjusting for other confounders, the maximum level of D-dimer during hospitalization (odds ratio [OR] 1.061, 95 % confidence interval (CI) 1.014–1.110), Glasgow coma scale (GCS) on admission (OR 1.347, 95 % CI 1.110–1.634), modified Rankin Scale (mRS) at discharge (OR 2.578, 95 % CI 1.546–4.298), neutrophil count (OR 1.056, 95 % CI 1.025–1.088) and hospitalization time (OR 1.089, 95 % CI 1.018–1.164) were independently associated with the sICH patients who developed VTE. The maximum D-dimer plasma level of 5.655 mg/L during hospitalization was the optimal threshold to indicate sICH patients developing VTE with a sensitivity of 83.3 % and a specificity of 67.4 %. No patients with sICH received prophylactic anticoagulation therapy against VTE in the present study. A total of 57.6 % (76/132) of the sICH patients with VTE were administered anticoagulant therapy and the rate of hemorrhagic complication was 9.2 %. ConclusionssICH patients with increased levels of D-dimer, higher GCS scores, higher mRS scores, increased neutrophil counts and longer hospitalization time are more likely to develop VTE complications. Routine and serial monitoring of the D-dimer values may be useful in patients with sICH, and VTE should be considered when the plasma level of D-dimer increases to 5.655 mg/L during hospitalization. In tertiary hospitals in China, the rate of sICH patients with VTE receiving anticoagulation treatment is low. Further studies are necessary to explore the safety and efficacy of VTE therapeutic anticoagulation in patients with sICH.

Single antiplatelet regimen in flow diverter treatment of cerebral aneurysms: The drug matters. A systematic review and meta-analysis.

Hemorrhagic and thromboembolic complications (TECs) are the main concerns in the endovascular treatment of intracranial aneurysms using flow diverter devices (FDs). The clinical demand for single antiplatelet therapy (SAPT) is increasing especially with the development of devices with lower thrombogenicity profile. However, the safety of SAPT is not well established. To analyze the safety and efficacy of SAPT in terms of ischemic and hemorrhagic complications in patients undergoing FDs treatment for cerebral aneurysms. A systematic literature search and meta-analysis were conducted in PubMed, Ovid MEDLINE, Ovid Embase, and Web of Science from January 2010 until October 2022. Twelve articles which reported SAPT and data on hemorrhagic, TECs, and mortality following FDs treatment were included. Overall, the 12 studies involved 237 patients with 295 aneurysms. Five investigated the safety and efficacy of SAPT in 202 unruptured aneurysms. Six studies focused on 57 ruptured aneurysms. One study included both ruptured and unruptured aneurysms. Among the 237 patients, prasugrel was most often used as SAPT in 168 cases (70.9%), followed by aspirin in 42 (17.7%) patients, and by ticagrelor in 27 (11.4%). Overall, the hemorrhagic complication rate was 0.1% (95% CI 0% to 1.8%). The TEC rate was 7.6% (95% CI 1.7% to 16.1%). In the subgroup analysis, the TEC rates of prasugrel monotherapy of 2.4% (95% CI 0% to 9.3%) and ticagrelor monotherapy of 4.2% (95% CI 0.1% to 21.1%) were lower than of aspirin monotherapy 20.2% (95% CI 5.9% to 38.6%). The overall mortality rate was 1.3% (95% CI 0% to 6.1%). According to the available data, SAPT regimen in patients undergoing FDs treatment for cerebral aneurysms has an acceptable safety profile, especially with the use of ADP-receptor antagonists.

Coiling Variations for Treatment of Ruptured Intracranial Aneurysms: A Meta-Analytical Comparison of Comaneci-, Stent-, and Balloon-Coiling Assistance Techniques

Wide-necked aneurysms represent a challenge for treatment in the setting of acute subarachnoid hemorrhage. Stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) are well-known techniques for treating wide-necked aneurysms. Comaneci-assisted coiling (CAC) is a newer technique involving temporary stent deployment to assist aneurysm coiling. We aim to present the first meta-analysis comparing these treatments of ruptured aneurysms. Following PRISMA guidelines, PubMed and Embase databases were queried from earliest records to July 2022 for literature reporting SAC, BAC, or CAC of ruptured intracranial aneurysms. A meta-analysis of identified articles was performed. Of the 571 articles queried, 64 articles were included. One study reported BAC and SAC, 8 reported BAC, 52 reported SAC, and 3 reported CAC. These studies comprised 3153 patients with 3207 ruptured aneurysms treated with CAC (161 patients and aneurysms), BAC (330 patients and aneurysms), and SAC (2662 patients, 2716 aneurysms). Rates of periprocedural thromboembolic or hemorrhagic complications, overall or procedure-related mortality, immediate complete occlusion, retreatment, and length of angiographic follow-up did not differ significantly between SAC and BAC. Periprocedural thromboembolic (P= 0.03) and hemorrhagic (P= 0.01) complication rates were higher with BAC than CAC. Periprocedural thromboembolic (P= 0.03) and hemorrhagic (P < 0.0001) complication rates were higher with SAC than CAC. Complete aneurysm occlusion rates (P= 0.033) were higher with CAC than BAC. No significant differences were present in CAC versus BAC or SAC retreatment rates. CAC was associated with lower hemorrhagic and thromboembolic complication rates and demonstrated similar complete occlusion and residual retreatment rates to those for BAC and SAC.

The safety profile of single antiplatelet therapy with flow diverters: Systematic review and meta-analysis

Dual antiplatelet therapy (DAPT) is frequently used in treating cerebral aneurysms with flow diverters (FDs), whereas single antiplatelet therapy (SAPT) is used mostly with coated FDs and in ruptured aneurysms. We conducted a systematic review and meta-analysis to explore the safety profile of SAPT in FDs. PubMed, Web of Science, OVID Embase, OVID Medline, and Scopus were searched to 1st November 2022. Outcomes of interest included ischemic and hemorrhagic complications, conversion to DAPTs, and in-stent stenosis rates under long-term SAPT. SAPT is divided into aspirin (ASA) vs. non-ASA group (ticagrelor or prasugrel). Subgroup analysis was performed for ruptured vs. non-ruptured aneurysms and coated vs. non-coated FDs. All data were analyzed using R software version 4.2.2. Twelve studies with 240 total patients (43 patients in the ASA group and 197 patients in the non-ASA group) were included in our meta-analysis. The pooled ischemic occlusion rate was 9.8% (95% CI = 4.87-18.95: p-value = 0.09) for SAPTs. The ASA group had significantly higher ischemic complication rates compared to the non-ASA group (20.8% vs. 6.3%, respectively, p-value = 0.02). The pooled hemorrhagic complication rate was 3.5% (95% CI = 1.38-8.81: p-value > 0.99). The hemorrhagic rates of ASA group were 9.3%% (95% CI = 3.54-22.30) over the non-ASA group 2.1% (95% CI = 0.58-7.54) (p-value > 0.99). The overall in-stent stenosis rate was 2.3% (95% CI = 1.06-5.14: p-value > 0.99). The ischemic complication rates were comparable between coated vs non-coated FDs (10.7% vs. 5.5% p-value = 0.39). In stent stenosis rate were 1.9% (95% CI = 0.72-4.96) in coated FDs over 4.4% (95% CI = 1.11-16.11) (p-value = 0.32). The ruptured and non-ruptured groups also showed comparable results in terms of ischemic (17.6% vs. 7.1% respectively, p-value = 0.24) and hemorrhagic complications (9.8% vs. 1.1%, respectively, p-value = 0.08). Flow diverter treatment under ASA monotherapy resulted in relatively high ischemic complication rates. However, SAPT with prasugrel or ticagrelor monotherapy is promising for coated FDs and ruptured aneurysm treatments. Given the overall small sample size and also the likely presence of known and unknown biases regarding choice of antiplatelet therapy between groups, larger cohort studies are needed to evaluate SAPT treatment outcomes.

Retrospective comparison of clinical outcomes of ultrasound-guided percutaneous cholecystostomy in patients with and without coagulopathy: a single center's experience.

To compare the complication rate and clinical outcomes for percutaneous cholecystostomy (PC) in patients with or without coagulopathy. We retrospectively reviewed electronic medical chart of patients who underwent ultrasound-guided PC with a 8.5-F drainage tube for acute cholecystitis between November 2003 and March 2017. We divided the patients into two groups: patients with coagulopathy (international normalized ratio > 1.5 or platelet count < 50 × 109/L or with a history of anticoagulant medication in preceding 5days) and patients without coagulopathy. Duration of drainage, duration of hospital stay, 30-day mortality and complication rates were compared between these two groups. Student's t test, Chi-square test or Fisher's exact test was used for bivariate analyses. Age, age-adjusted Charlson Comorbidity Index (ACCI) and sepsis-adjusted complication rates were also compared. In total, 141 patients had PC (mean age was 73.3 years [SD 13.3]; range 33-96 years; 94 men and 47 women). Fifty-two patients (36.9%) had coagulopathy and 89 patients (63.1%) were without any history of coagulopathy. Hemorrhagic complication rate was 3.5% (5 out of 141 patients, including 4 with coagulopathy and 1 without). One patient with coagulopathy died due to the hemorrhage. Duration of drainage was longer in patients with coagulopathy than patients without coagulopathy (20.0days vs. 14.8days; P = 0.033). No significant difference was observed with regard to duration of hospital stay (32.3days vs. 25.6days; P = 0.103) and 30-day mortality (7.7% vs. 1.1%; P = 0.062). The overall complication rate did not significantly differ (9.6% and 11.2%; P = 0.763), nor did age, ACCI or sepsis-adjusted complications. Clinical outcomes and complications rates after PC did not statistically differ between patients with and without coagulopathy, but there was a tendency of higher risk of hemorrhage in coagulopathy patients. Therefore, the indication of this procedure should be carefully determined.

482 Triple Therapy Versus Dual Antiplatelet Therapy for Dolichoectatic Vertebrobasilar Fusiform Aneurysms Treated With Flow Diverters: The Last Frontier?

INTRODUCTION: Dolichoectatic vertebrobasilar fusiform aneurysms (DVBFAs) have poor natural history when left untreated and high morbimortality when treated with microsurgery. Flow diversion (FD) with dual-antiplatelet therapy (DAPT) is feasible but carries a high risk of perforator occlusion and progression of brainstem compression. Seeking better hopes for these patients, experts across the US started using triple-therapy (DAPT plus oral anticoagulation) after FD treatment in attempt to improve their clinical outcomes. The rationale was to preserve perforator patency while vessel remodeling occurs. The current study is the result of this multicenter effort. METHODS: Retrospective data collection from 8 US centers. Only DVBFAs treated with flow-diversion and either triple-therapy or DAPT alone were included. Patient and aneurysms' characteristics, and clinical and angiographic outcomes were compared. RESULTS: The groups (DAPT, n = 13 vs Triple-therapy, n = 14) were similar in age, sex, clinical presentation, baseline disability, aneurysm characteristics, median number of flow-diverters, and adjunctive coiling. Radial access use was significantly higher in the triple-therapy group (71.4% vs. 15.3%, P = 0.006). Acute ischemic stroke rate was lower in the triple-therapy group (7.1% vs. 30.8%, P = 0.167). Overall rate of modified Rankin Scale score decline due to either ischemic stroke or worsening of brainstem compression was significantly lower in the triple-therapy group (7.1% vs. 69.2%, P = 0.001). Overall rate of hemorrhagic complications was numerically higher in the triple-therapy group (28.6% vs. 7.7%, P = 0.162). The rate of moderate-to-severe disability at last follow-up was significantly lower in the triple-therapy group (21.4% vs. 76.9%, P = 0.007). I. CONCLUSIONS: Patients with DVBFAs treated with FD and triple-therapy had less ischemic strokes, less symptom progression, and overall better outcomes at last follow-up than similar patients and aneurysms managed with DAPT alone.

396 North American Multicenter Experience of the Flow-Redirection Endoluminal Device (FRED) in the Treatment of Intracranial Aneurysms

INTRODUCTION: Flow-diverters have revolutionized the endovascular treatment of intracranial aneurysms. The evidence on the Flow Re-direction Endoluminal Device (FRED) is limited compared to some counterparts that have been available for clinical use longer. METHODS: Between June 2020 and November 2021, consecutive cerebral aneurysms treated using FRED were included across 7 North American centers. Data collected included patient demographics, aneurysm characteristics, peri-procedural and long-term complications, modified Rankin Scale (mRS) scores, and radiologic follow-up. RESULTS: 133 aneurysms in 116 patients treated in 123 FRED deployment procedures were included. One hundred twenty-six aneurysms (94.7%) were unruptured, 117 (88.0%) were saccular, and 123 (92.5%) aneurysms were located in the anterior circulation. Mean aneurysm maximal width and neck sizes were 7.2 mm and 4.1 mm, respectively. Successful FRED deployment was achieved in 122 (99.2%) procedures. Radiologic follow-up was available for 101 aneurysms at a median duration of 7.0 months. At the last follow-up, complete occlusion was observed in 55.4%, residual neck in 8.9%, and filling aneurysm in 35.6%. On multivariate regression analysis, age (OR = 0.93; p = 0.001) and aneurysm neck size (OR = 0.83; p = 0.048) negatively correlated with odds of complete occlusion. The retreatment rate was 6/124 (4.8%). The overall complication rate was 31/116 (26.7%). Parent vessel occlusion, covered branch occlusion, and in-stent stenosis were detected in 9/99 (9.1%), 6/63 (9.5%), and 15/99 (15.2%) of the cases, respectively. FRED-related, symptomatic, thromboembolic, and hemorrhagic complication rates were 22.4%, 12.9%, 6.9%, and 0.9% respectively. The morbidity rate was 10/116 (8.6%). CONCLUSIONS: As the first large-scale North American multi-center FRED experience, this study confirms FRED’s ease of successful deployment but suggests a lower efficacy and higher rate of complications compared to previous European and South American FRED studies and other flow diverting devices.

Correct Stapling Technique in Laparoscopic Sleeve Gastrectomy: Are We Increasing the Bleeding? A Prospective Cohort Study.

Introduction: Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric surgery procedure. Bleeding is the most common complication of this surgery and mostly occurs from the staple line. The aim of this study was to evaluate whether waiting between compression and firing during the stapling phase reduces the postoperative bleeding. Methods: A total of 325 patients who underwent LSG between April and July 2022 were analyzed prospectively. In terms of postoperative bleeding, the two groups, which we waited 30 seconds between staple firings and the no wait group, were compared. Results: The mean age of patients was 37.36 (±11.12) years and mean body mass index was 45.18 (±3.1) kg/m2. Eleven patients needed transfusion. The rate of haemorrhagic complications was 3.38% (Group 1% 6.21 and Group 2% 1.11) (P = .012). The duration of surgery was ∼10 minutes longer in the study group, which we waited (P = .0001). Conclusions: During the stapling stage in LSG, waiting between compression and firing can help reduce postoperative bleeding.

Modern intracranial electroencephalography for epilepsy localization with combined subdural grid and depth electrodes with low and improved hemorrhagic complication rates.

Recent trends have moved from subdural grid electrocorticography (ECoG) recordings toward stereo-electroencephalography (SEEG) depth electrodes for intracranial localization of seizures, in part because of perceived morbidity from subdural grid and strip electrodes. For invasive epilepsy monitoring, the authors describe the outcomes of a hybrid approach, whereby patients receive a combination of subdural grids, strips, and frameless stereotactic depth electrode implantations through a craniotomy. Evolution of surgical techniques was employed to reduce complications. In this study, the authors review the surgical hemorrhage and functional outcomes of this hybrid approach. A retrospective review was performed of consecutive patients who underwent hybrid implantation from July 2012 to May 2022 at an academic epilepsy center by a single surgeon. Outcomes included hemorrhagic and nonhemorrhagic complications, neurological deficits, length of monitoring, and number of electrodes. A total of 137 consecutive procedures were performed; 113 procedures included both subdural and depth electrodes. The number of depth electrodes and electrode contacts did not increase the risk of hemorrhage. A mean of 1.9 ± 0.8 grid, 4.9 ± 2.1 strip, and 3.0 ± 1.9 depth electrodes were implanted, for a mean of 125.1 ± 32 electrode contacts per patient. The overall incidence of hematomas over the study period was 5.1% (7 patients) and decreased significantly with experience and the introduction of new surgical techniques. The incidence of hematomas in the last 4 years of the study period was 0% (55 patients). Symptomatic hematomas were all delayed and extra-axial. These patients required surgical evacuation, and there were no cases of hematoma recurrence. All neurological deficits related to hematomas were temporary and were resolved at hospital discharge. There were 2 nonhemorrhagic complications. The mean duration of monitoring was 7.3 ± 3.2 days. Seizures were localized in 95% of patients, with 77% of patients eventually undergoing resection and 17% undergoing responsive neurostimulation device implantation. In the authors' institutional experience, craniotomy-based subdural and depth electrode implantation was associated with low hemorrhage rates and no permanent morbidity. The rate of hemorrhage can be nearly eliminated with surgical experience and specific techniques. The decision to use subdural electrodes or SEEG should be tailored to the patient's unique pathology and surgeon experience.

Risk of Complications in Patients Undergoing Complete Thyroidectomy. A Retrospective Study

Introduction: The main aim of this study was to determine the influence of surgery on postoperative complications in patients undergoing total thyroidectomy. Methods: Patients diagnosed with goiter and undergoing total thyroidectomy for more than ten years were retrospectively enrolled, and the main study outcomes were postoperative complications. Statistical analysis was done by chi-square and t-test with a p-value &lt;0.05 as significant. Results: A total of 116 patients with goiter were identified (mean age, 45.3 ± 8.75 years, with minimum and maximum age of 23 to 69). The most affected age with goiter resulted in 41-50 years old with 41.4% (95% CI, 37.4 to 45.8%). The majority of patients with goiter were women (85.3%), with a mean age of 47 years. After the thyroid surgery, male patients had significantly higher rates of hospital readmission than females with a risk ratio [RR] of 1.05; 95% CI [0.67–1.52], p-value = 0.02. Either hemorrhage/hematoma occurred in 4.7% and cardiopulmonary and thromboembolic events in 3.1% of the patients undergoing total thyroidectomy. In addition, either hypoparathyroidism was observed in 3.1% and temporary recurrent laryngeal nerve palsy (RLN) in 1.56%. Conclusion: The current study demonstrates that total thyroidectomy is associated with an increased rate of hemorrhagic complications. RLN palsies and hypoparathyroidism are less observed. Male patients undergoing thyroidectomy have higher rates of readmission and ICU admission. Furthermore, male patients revealed higher rates of hemorrhage and wound infection, while hypoparathyroidism or temporary recurrent laryngeal nerve palsy was more frequent among female patients.

A comparison of antiplatelet therapy during the peri- and post-operative periods following flow-diverting stent insertion for unruptured intracranial aneurysms: A systematic review.

Flow diverters (FDs) are neuroendovascular stents indicated for the management of unruptured intracranial aneurysms. Due to their composition, dual antiplatelet therapy (DAPT) is essential during the peri- and post-operative periods to prevent thromboembolic events. However, there is limited consensus within the scientific community regarding which antiplatelets to use and dosing following neuroendovascular treatment of aneurysms. A systematic search of four electronic databases was conducted during November 2020 that included studies published between January 2010 and November 2020. Eligibility for inclusion included primary research articles, published in the English language and use of flow-diverting intracranial stents. Studies were excluded if they utilised combined therapies (e.g. FD with stent-assisted coiling), animal studies, clinical trial protocols and study population of less than 10 subjects. Eighteen studies were identified for inclusion with a total of 1312 patients with 1355 unruptured intracranial aneurysms treated with FDs. Of these, 13 studies primarily investigated the use of clopidogrel with aspirin with low rates of haemorrhagic and thromboembolic complications. A forest plot of nine of these studies showed average efficacy of 88% at 95% confidence interval (CI) (SD + 5%) with 63% heterogeneity. The large proportion of studies investigating clopidogrel and aspirin antiplatelet therapy presents a challenge in comparing antiplatelet regimens. Although prasugrel and ticagrelor have been identified as suitable alternatives to clopidogrel, these were based on studies with small cohort sizes. Glycoprotein IIb/IIIa inhibitors may be efficacious as rescue therapy for intra-procedural thrombosis. Further research is required to determine which antiplatelet is most suitable.

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease