Intraprocedural Complications Research Articles

Efficacy and safety of very high-power short-duration posterior wall ablation in persistent atrial fibrillation: a propensity score-matched comparison with standard power long-duration ablation

Abstract Background Catheter ablation (CA) with pulmonary vein isolation (PVI) is an optimal treatment option in patients with paroxysmal atrial fibrillation (AF). PVI alone in patients with persistent AF has proved to have suboptimal results. Ablation of additional atrial structures, such as posterior wall (PW) and left atrial appendage has been investigated as a tool to improve procedural efficacy. Recently very high-power short-duration (vHPSD) ablation was developed to allow rapid PVI, limiting complication through the maximization of resistive heating, and minimization of conductive heating. Objectives Compare PVI plus PWI using vHPSD versus standard-power (SP) ablation index-guided CA among consecutive patients with persistent AF Methods Forty consecutive patients underwent PVI plus PW isolation using vHPSD, compared to 40 controls underwent standard power (SP) PVI plus PW isolation. The primary efficacy endpoint outcome was recurrence of atrial tachyarrhythmias after a 3-month blanking period. The primary safety outcome was a composite of major complications within 30 days of CA. Results Treated patients have a median age of 62.8±9 years, 68 (85%) are male. Median left atrial volume is 42.4 (36-50) ml/m2. 61 (78.8%) patients had never undergone catheter ablation before. There are no statistically significant differences between groups. PW isolation was obtained more commonly in the vHPSD compared to the SP group (98% vs. 75%, p=0.007), despite shorter procedure and fluoroscopy times (p<0.001). Survival free from recurrent atrial tachyarrhythmias at 18 months was 68% in the vHPSD and 47% in SP groups, respectively (log-rank p=0.071), without major adverse events. The vHPSD approach was significantly associated with reduced risk of recurrent AF at multivariable analysis (HR, 0.39, p=0.030). Conclusions The results show feasibility and safety of posterior wall vHPSD ablation for persistent AF using this new temperature-controlled catheter without intraprocedural and periprocedural major complications at follow-up. vHPSD ablation for PW isolation may be more effective in term of atrial tachyarrhythmias recurrences with a trend for superior efficacy. However, this remains a single center experience in a small group of patients. Comparative trials involving greater number of patients with long-term follow-up are necessary to definitive results.

Digital health in the electrophysiological lab: Initial experience, safety and feasibility using remote support for arrhythmia ablation-Results of REMOTE-VA study

Abstract Background In most electrophysiology (EP) labs, electroanatomical mapping (EAM) systems are operated on site by qualified staff or field technical engineers (FTE). Due to lack of skilled personnel, the FTE usually must travel between different hospitals and procedures must be planned in advance. Ablation of ventricular arrhythmias (VA) represents the most complex procedure in the field. The use of remote support (RS) to guide complex EP procedures has the potential to increase flexibility, reduce travel times and maximise healthcare resources. Purpose To evaluate the safety and feasibility of RS as compared to on-site support guided catheter ablation procedures for VA. Methods All patients undergoing ventricular tachycardia (VT) or premature ventricular complex (PVC) ablation using remote support were included. The electronical system of the hospital was searched for 30 days postprocedural emergency department (ED) visits, unplanned ambulatory presentations, and readmissions. RS guided three-dimensional (3D) mapping was achieved by connecting the EAM software with an integrated audio-visual solution for remote support. Internet connection-based headphones and high-resolution cameras ensured the communication between the operator and the FTE, who worked exclusively from home office. The control group consisted of an equal number of patients matched for the type of procedure and undergoing on-site guided procedures. All ablations were performed using high density 3D mapping, as per institutional standard. Results Between October 2022 and October 2023, a total of 25 patients underwent VT (32%) or PVC ablation in our centre using RS and were compared to 25 patients undergoing the same procedures under on-site guidance. In the RS group one patient underwent epicardial VT ablation and another one bipolar ablation for VT Storm. The demographic data were similar between the groups. The median procedure time was 120 (93, 143) minutes in the RS group and 112 (95, 138) minutes in the control group (p=0.95), while the fluoroscopy time was 11.4 (7.0, 14.0) and 7.26 (5.0, 10.9) minutes respectively (p=0.08). The procedural success was achieved in 96% procedures in the RS group and in 100% in the control group. No technical issues or changes to on-site support were reported. One minor intraprocedural complication was noted among the control patients, while 24% of the patients in each group developed minor complications until discharge. Two patients in the RS group and one in the control group had ED visits, while only one patient in the control group had an unplanned ambulatory presentation. One unplanned readmission was reported in the control group (Table 1). Conclusions Even in the most complex procedures including epicardial ablation, the use of RS was feasible and safe in this single centre study. This approach has the potential to increase the feasibility in case of emergency procedures, reduce travel times, and maximise healthcare resources.

A RARE COMPLICATION OF MITRAL TEER PROCEDURE: CLIP LATE DETACHMENT AND EMBOLIZATION

Abstract Intraprocedural and late complications of MitraClip implantation have already been described. This report highlights the importance of conventional surgical options in the event of percutaneous treatment failure. An 85–year–old woman with a history of chronic anemia, and thalassemia Minor was referred to our clinic for severe mitral regurgitation (MR) due to a P2 flail with significant calcification of the posterior mitral annulus. During the Heart Team discussion, age and comorbidities led to consider the patient eligible for TEER with the MitraClip system (EuroSCORE II 9,34%; STS score 7,47%). TEER procedure was uneventful: one XTW was deployed at the level of the flail (A2–P2), a second XTW was then placed more lateral to treat a separate residual jet, and one NTW was finally placed between them. MR reduction was considered acceptable (moderate MR, mean grad 6 mmHg). After two months, symptoms worsened, and TTE showed severe MR (no device detachment) with increased sPAP and associated moderate TR. A couple of weeks later, the patient was hospitalized. Chest X–ray revealed clip embolization confirmed by coronary angiography that showed an XTW Clip embolized to the Right coronary sinus with partial occlusion of the ostium. Percutaneous clip retrieval is described in the literature, but the embolized device position and the presence of recurrent severe MR led us to prefer an urgent surgical intervention. Under CPB, the embolized XTW was easily retrieved through a small aortotomy; the intervention was completed by mitral valve replacement and tricuspid valve repair. The postoperative course was uneventful. Predischarge TTE showed normal mitral bioprosthesis function, mild AR, mild TR, and preserved LV function. DISCUSSION Clip embolization is a rare but potentially critical complication of TEER and can happen periprocedurally or on early follow–up. Single leaflet detachment is more common, but complete detachment and embolization can occur. Therapeutic options are represented by surgical or transcatheter approaches according to embolization sites and patient comorbidities. In our case, the risk of potential coronary obstruction or thrombosis and the concomitant need for MR treatment have led us to consider surgery as the first option. CONCLUSION TEER can be graved by acute or late complications. The best approach has to be tailored to each patient, and surgery can be an effective and safe option even for initially discarded high–risk patients.

Percutaneous Endoscopy and Image-guided Retrieval of Dropped Gallstones - A Case Series.

Recurrent abscesses can happen due to dropped gallstones (DGs) after laparoscopic cholecystectomy (LC). Recognition and appropriate percutaneous endoscopy and image-guided treatment options can decrease morbidity associated with this condition. We report a minimally invasive endoscopy and image-guided technique for retrieval of dropped gallstones in a series of 6 patients (M/F=3/3; median age: 75.5 years [68 to 82]) presenting with recurrent or chronic intra-abdominal abscesses secondary to dropped gallstones. Technical success was defined as the visualization and retrieval of all stones. DGs were identified on pre-procedure imaging. Number of abscesses recurrence was 12 (1/6), 1 (3/6), and 0 (2/6) with a median interval of 2 months (1 to 21) between cholecystectomy and abscess development. Percutaneous endoscopy and fluoroscopy guidance were utilized in all cases. Technical success was achieved in 4 patients (66%). The median procedure time was 65.8 minutes (39 to 136). The median fluoroscopy time and dose were 12.6 min (3.3 to 67) and 234 mGy (31 to 1457), respectively. There were no intraprocedure and postprocedure complications. No abscess recurrence was reported among successful procedures during a median follow-up of 193 days (51 to 308). Percutaneous image and endoscopy-guided lithotripsy/lithectomy are safe and effective. This technique is a suitable alternative to open surgery for dropped gallstones. Level 4, Case Series.

Novel, braided, self-expandable stent designed for the treatment of pulsatile tinnitus caused by intracranial venous stenosis: first-in-human experience and long-term outcomes

BackgroundPulsatile tinnitus (PT) can be a disabling clinical condition, which may be caused by a sigmoid/transverse sinus stenosis (STSS). Intracranial venous stenting with off-label carotid or peripheral venous stents has...

213 Acute Flow Diversion for Ruptured Cerebral Aneurysms Arising From Vessels of Small Caliber Using FRED Jr: A Clinical Case Series

INTRODUCTION: Ruptured aneurysms arising from small caliber (<2.5 mm) or distal vessels beyond the circle of Willis are considered challenging for all treatment modalities. Recently, the FRED Jr stent, designed for flow diversion in small arteries, was approved in the US for the treatment of non-ruptured aneurysms. METHODS: Clinical and radiological records of patients sustaining SAH treated with FRED Jr between June 2020 and October 2022 were reviewed. Treatment course including anti-platelet therapy, external ventricular drain (EVD) management, and vasospasm, as well as clinical outcomes were analyzed. Angiographic results were assessed according to the O’Kelly-Marotta (OKM) scale. RESULTS: Nine patients with at a median age of 62 (27-75) were included. The median Hunt Hess score was 2 (IQR 1) and modified Fischer score was 4 (IQR 1). Six aAneurysms’ morphologies included were saccular (6 case), 1 blister (1 case) and 2 were and dissecting (2 cases) type, located at the ACOM complex (3), A2/A3 (3), M2/M3 (1), V4 (1), and P2 (1) segments. All stents were deployed successfully with no intraprocedural complications. Post-operatively, no re-bleeding events were encountered. Vasospasm therapy was initiated in 6 cases, and no symptomatic EVD-related hematomas were observed. Post- operative ischemic events were encountered in 2 cases. Median 3-month mRS was 2 (IQR 1) for the7 surviving patients, and 3-months radiographic follow-up revealed OKM scale D in 4/7 cases. CONCLUSIONS: Flow diversion as a potential treatment strategy for acutely ruptured aneurysms arising from small caliber vessels is feasible using FRED Jr. Since As the complication profile reported in this series is comparable to historical microsurgical cohorts and effective protection was conferred by this treatment modality, our small cohort provides a glimpse into acute flow diversion for this subset of difficult-to-treat aneurysms.

Low-Profile Visualized Intraluminal Support Device for Y-Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms: A Single-Center Experience

BackgroundThe Low-Profile Visualized Intraluminal Support (LVIS) device has been frequently used as intracranial stent for treating intracranial aneurysms. However, the feasibility and efficacy of LVIS devices in Y-stent-assisted coiling (Y-SAC) have remained contentious. This study aimed to evaluate long-term angiographic and clinical outcomes of Y-SAC using LVIS devices. MethodsWe retrospectively reviewed the clinical presentation and angiography data of patients treated with Y-SAC using LVIS stents. The vascular angle geometry between the parent and the two branch vessels, before and after stent deployment and after coiling were analyzed. Based on Raymond-Roy Occlusion Classification (RROC), aneurysm occlusion status was classified. Clinical outcomes were assessed using the modified Rankin Scale (MRS). ResultsForty patients with 40 aneurysms were included in this study. Immediate postprocedural angiograms revealed complete/near-complete occlusion (RROC 1 and 2) in 31 aneurysms (77.5%). The long-term follow-up angiographic studies were available in 32 patients revealing RROC class 1 and 2 in 93.8% of patients. Y-SAC with LVIS devices significantly decreased the angle between the bifurcation branches from 171.90 ° ± 48.0° (SD) to 130.21° ± 46.3° (SD) (p<0.0001). Periprocedural complications occurred in five patients (12.5%) including four in-stent thrombosis (10.5%). Thirty-six patients (90.0%) had favorable clinical outcomes at the final follow-up. Univariate analysis depicted that WFNS of 3-5, thick of subarachnoid hemorrhage on head CT scan, intraprocedural complications, and in-stent thrombosis were predictors of poor outcome. ConclusionY-SAC using LVIS device for intracranial bifurcation aneurysms is a feasible and relatively safe procedure with favorable long-term angiographic and clinical outcomes.

Low Left-Ventricular Ejection Fraction as a Predictor of Intraprocedural Cardiopulmonary Resuscitation in Patients Undergoing Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve replacement (TAVR) has become an established alternative to surgical aortic valve replacement (AVR) for patients with moderate-to-high perioperative risk. Periprocedural TAVR complications decrease with growing expertise of implanters. Nevertheless, TAVR can still be accompanied by life-threatening adverse events such as intraprocedural cardiopulmonary resuscitation (CPR). This study analyzed the role of a reduced left-ventricular ejection fraction (LVEF) in intraprocedural complications during TAVR. Perioperative and postoperative outcomes from patients undergoing TAVR in a high-volume center (600 cases per year) were analyzed retrospectively with regard to their left-ventricular ejection fraction. Patients with a reduced left-ventricular ejection fraction (EF ≤ 40%) faced a significantly higher risk of perioperative adverse events. Within this cohort, patients were significantly more often in need of mechanical ventilation (35% vs. 19%). These patients also underwent CPR (17% vs. 5.8%), defibrillation due to ventricular fibrillation (13% vs. 5.4%), and heart-lung circulatory support (6.1% vs. 2.5%) more often. However, these intraprocedural adverse events showed no significant impact on postoperative outcomes regarding in-hospital mortality, stroke, or in-hospital stay. A reduced preprocedural LVEF is a risk factor for intraprocedural adverse events. With respect to this finding, the identified patient cohort should be treated with more caution to prevent intraprocedural incidents.

Optional management of failed endovascular intervention for infrainguinal arterial occlusive disease

Introduction Endovascular treatment is increasingly chosen as the first option for treating infrainguinal peripheral arterial disease. Although open surgical bypass provides the most durable option for limb salvage, it has substantial morbidity and mortality. Aim The aim of the study is to determine the causes of failure of endovascular intervention and treatment modalities of failed endovascular intervention and results of each modality. Patients and methods A prospective case series study that addresses the outcomes of managing 40 patients with chronic limb ischemia due to femoropopliteal disease treated by endovascular intervention, and the intervention was failed. Causes of failure within 30 days were analyzed. Results We had 13 (27.5%) females and 27 (72.5%) males; their age ranged from 45 to 77 years with a mean of 62.20±7.44. Presentation with rest pain: three (7.5%) patients, minor tissue loss: 18 (45%) patients, major tissue loss: 19 (47.5%) patients the length of lesion was between 5 and 10 cm in three (7.5%) patients and more than 10 cm in 37 (92.5%) patients. Runoff in anterior tibial artery: 23 (57.5%) patients, posterior tibial artery: 19 (47.5%) patients, and peroneal artery: 15 (37.5%) patients. We had no complications in 26 (65%) patients, failure to pass in 12 (30%) patients, and distal embolization in two (5%) patients as intraprocedural complications. During the 30-day follow-up: Acute stent thrombosis in 7 (17.5%) cases, flow-limiting dissection in 8 (20%) cases, residual stenosis in 3 (7.5%) cases, acute thrombosis in 2 (5%) cases, missed iliac lesions in 2 (5%) cases, post-procedural distal arterial tree embolization in 2 (5%) cases, and clinical failure was the cause in 2 (5%) cases. The management was: Redo endovascular in 18 (45%) patients, surgical bypass in 14 (35%) patients, primary amputation in six (15%) patients, and medical treatment in two (5%) patients. After 6 months follow-up limb salvage was in 57.5% of the cases with transmetatarsal amputation in 69.6% of them and major amputation was in 42.5% of the cases Conclusion Failed endovascular intervention procedures within 30 days were associated mainly with long lesions. So, surgical bypass appeared to be superior to endovascular intervention for long lesions. Improvements in endovascular equipment and angioplasty technique might ultimately improve the outcome results and decrease the failure rate of endovascular interventions

Safety and efficacy of early carotid artery stenting in patients with symptomatic stenosis.

Symptomatic carotid artery stenosis is a significant contributor to ischemic strokes. Carotid artery stenting (CAS) is usually indicated for secondary stroke prevention. This study evaluates the safety and efficacy of CAS performed within a short time frame from symptom onset. We conducted a single-center, retrospective study of consecutive patients who underwent CAS for symptomatic carotid stenosis within eight days of symptom onset from July 2019 to January 2022. Data on demographics, medical history, procedural details, and follow-up outcomes were analyzed. The primary outcome measure was the recurrence of the stroke within the first month post-procedure. Secondary outcomes included mortality, the rate of intra-procedural complications, and hyperperfusion syndrome. We included 93 patients with a mean age of 71.7 ± 11.7 years. The median time from symptom onset to CAS was 96 h. The rate of stroke recurrence was 5.4% in the first month, with a significant association between the number of stents used and increased recurrence risk. Mortality within the first month was 3.2%, with an overall mortality rate of 11.8% after a median follow-up of 19 months. Intra-procedural complications were present in five (5.4%) cases and were related to the number of stents used (p = 0.002) and post-procedural angioplasty (p = 0.045). Hyperperfusion syndrome occurred in 3.2% of cases. Early CAS within the high-risk window post-symptom onset is a viable secondary stroke prevention strategy in patients with symptomatic carotid artery stenosis. The procedure rate of complication is acceptable, with a low recurrence of stroke. However, further careful selection of patients for this procedural strategy is crucial to optimize outcomes.

Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians: A United States national experience.

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic tool for biliary and pancreatic diseases. Frail and elderly patients, especially those aged ≥ 90 years are generally considered a higher-risk population for ERCP-related complications. To investigate outcomes of ERCP in the Non-agenarian population (≥ 90 years) concerning Frailty. This is a cohort study using the 2018-2020 National Readmission Database. Patients aged ≥ 90 were identified who underwent ERCP, using the international classification of diseases-10 code with clinical modification. Johns Hopkins's adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail. The primary outcome was mortality, and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP. We used univariate and multivariate regression models for analysis. A total of 9448 patients were admitted for any indications of ERCP. Frail and non-frail patients were 3445 (36.46%) and 6003 (63.53%) respectively. Indications for ERCP were Choledocholithiasis (74.84%), Biliary pancreatitis (9.19%), Pancreatico-biliary cancer (7.6%), Biliary stricture (4.84%), and Cholangitis (1.51%). Mortality rates were higher in frail group [adjusted odds ratio (aOR) = 1.68, P = 0.02]. The Intra-procedural complications were insignificant between the two groups which included bleeding (aOR = 0.72, P = 0.67), accidental punctures/lacerations (aOR = 0.77, P = 0.5), and mechanical ventilation rates (aOR = 1.19, P = 0.6). Post-ERCP complication rate was similar for bleeding (aOR = 0.72, P = 0.41) and post-ERCP pancreatitis (aOR = 1.4, P = 0.44). Frail patients had a longer length of stay (6.7 d vs 5.5 d) and higher mean total charges of hospitalization ($78807 vs $71392) compared to controls (P < 0.001). The 30 d all-cause readmission rates between frail and non-frail patients were similar (P = 0.96). There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail. Larger studies are warranted to investigate and mitigate modifiable risk factors.

Novel Strategies for the Hostile Iliac Artery during Endovascular Aortic Aneurysm Repair.

Successful endovascular aneurysm repair can be achieved with favorable aortic and iliac arterial anatomies. However, patients with challenging iliac anatomy, such as stenotic, calcified, tortuous arteries, or concomitant iliac artery aneurysms, are commonly encountered. Such a hostile iliac anatomy increases the risk of intraprocedural complications and worsens long-term outcomes. This review addresses various technical options for treating patients with a hostile iliac anatomy, including innovative endovascular solutions, physician-modified endografts, and hybrid procedures. These considerations demonstrate the wide scope of therapies that may be offered to patients with an unfavorable iliac anatomy.

The Effect of Aortic Angulation on Clinical Outcomes of Patients Undergoing Transcatheter Aortic Valve Replacement.

The aim of this study was to assess the impact of aortic angulation (AA) on periprocedural and in-hospital complications as well as mortality of patients undergoing Evolut™ R valve implantation. A retrospective study was conducted on 264 patients who underwent transfemoral-approach transcatheter aortic valve replacement with self-expandable valve at our hospital between August 2015 and August 2022. These patients underwent multislice computer tomography scans to evaluate AA. Transcatheter aortic valve replacement endpoints, device success, and clinical events were assessed according to the definitions provided by the Valve Academic Research Consortium-3. Cumulative events included paravalvular leak, permanent pacemaker implantation, new-onset stroke, and in-hospital mortality. Patients were divided into two groups, AA ≤ 48° and AA > 48°, based on the mean AA measurement (48.3±8.8) on multislice computer tomography. Multivariable logistic regression analysis was performed to identify predictors of cumulative events, utilizing variables with a P-value < 0.2 obtained from univariable logistic regression analysis, including AA, age, hypertension, chronic renal failure, and heart failure. AA (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 0.89-3.38, P=0.104), age (OR: 1.04, 95% CI: 0.99-1.10, P=0.099), hypertension (OR: 1.66, 95% CI: 0.82-3.33, P=0.155), chronic renal failure (OR: 1.82, 95% CI: 0.92-3.61, P=0.084), and heart failure (OR: 0.57, 95% CI: 0.27-1.21, P=0.145) were not found to be significantly associated with cumulative events in the multivariable logistic regression analysis. This study demonstrated that increased AA does not have a significant impact on intraprocedural and periprocedural complications of patients with new generation self-expandable valves implanted.

Transvenous embolization of noncavernous dural arteriovenous fistulas (dAVFs): A systematic review and meta-analysis.

Intracranial dural arteriovenous fistulas (dAVFs) are abnormal connections between arteries and veins within the dura mater. Various treatment modalities, such as surgical ligation, endovascular intervention, and radiosurgery, aim to close the fistulous connection. Although transvenous embolization (TVE) is the preferred method for carotid-cavernous fistulas, its description and outcomes for noncavernous dAVFs vary. This has prompted a systematic review and meta-analysis to comprehensively assess the effectiveness of TVE in treating noncavernous dAVFs, addressing variations in outcomes and techniques. We searched PubMed and Embase, spanning from the earliest records to December 2022, to identify pertinent English-language articles detailing the utilization of TVE. We focused on specific procedural details, outcomes, and complications in patients older than 18 years. The data collected and analyzed comprised the sample size, number of fistulas, publication specifics, presenting symptoms, fistula grades, and pooled rates of embolizations, outcomes, follow-up information, and complications. From a total of 565 screened articles, 15 retrospective articles encompassing 166 patients spanning across seven countries met the inclusion criteria. Their Newcastle-Ottawa scores ranged from 6 to 8. Intraprocedural complication rate was 10% (95% confidence interval [CI] = 5.9-17.1) and in-hospital postprocedural complication rate was 5.4% (95% CI = 2.8-10.6). Prevalence of in-hospital mortality was 5.5% (95% CI = 2.9-10.6). Complication rate during follow-up was 8.6% (95% CI = 4.7-15.7) with fistula rupture occurring in 5.5% (95% CI = 2.6-11.6) of patients. Complete obliteration rate at final angiographic follow-up was 94.9% (95% CI = 90.3-99.9). Symptoms improved in 95% (95% CI = 89.8-100) of patients at final follow-up. To our knowledge, we present the first meta-analysis assessing obliteration rates, outcomes, and complications of TVE for dAVFs. Our analysis highlights the higher (>90%) complete obliteration rates. Large prospective multicenter studies are needed to better define the utility of TVE for noncavernous dAVFs.

Use of Rotational Atherectomy-Assisted Balloon Angioplasty in the Treatment of Isolated Below-the-Knee Atherosclerotic Lesions in Patients with Chronic Limb-Threatening Ischemia.

The aim of the study is to evaluate the safety and effectiveness of rotational atherectomy-assisted balloon angioplasty (BTK-RA) for the treatment of isolated below the knee (BTK) atherosclerotic lesions and to compare the outcomes to plain old balloon angioplasty (POBA). Between January 2020 and September 2023, 96 consecutive patients with chronic limb threatening ischemia (CTLI) and isolated BTK-lesions underwent POBA (group A) or BTK-RA (group B). The primary outcome measures were: periprocedural technical success, primary patency, postoperative increase of the ankle branchial index (ABI), target lesion revascularization (TLR), limb salvage, minor amputation and death. Both techniques had similar technical success, operative time, intraprocedural complications and bailout stent implantations, independently of the operator's experience. Group B had significantly higher primary patency rates (93.5% vs. 72.0%, respectively, p = 0.006), TLR (2.1% vs. 24%, p = 0.057), lower in-hospital stay (2.0-3.0 vs. 4.0-6.0 days, respectively, p < 0.001) and higher postoperative ABI (0.8-0.2 vs. 0.7-0.1, respectively, p = 0.008), compared to group A. Significant differences (POBA n: 20, 40%, BTK-RA n = 3, 6.5%) were found in minor amputation rates between the two groups (p < 0.001), while the respective limb salvage rates were similar in both groups (94.0% vs. 97.8%, p = 0.35). The use of BTK-RA for the treatment of BTK-lesions in patients with CTLI showed significant clinical advantages in comparison to POBA.

Intra-pericardial thrombin injection in iatrogenic cardiac tamponade: a case report

BackgroundNowadays, percutaneous procedures are expanding in use, and this comes with complications associated with the procedure itself. Cardiac tamponade is rare but may be life threatening since it can involve hemodynamic instability. It is known that after pleural effusion during a percutaneous procedure, pericardiocentesis should be used as drainage of the cavity. However, that does not achieve hemostasis in some cases, and in those patients who are hemodynamically unstable, a sealing agent to promote hemostasis might be useful, like thrombin.Case presentationWe present a case report of 89-year-old patient with history of melanoma undergoing treatment with pembrolizumab, who attended the emergency department referring chest pain (intensity 5/10) and palpitations that have lasted hours. He had TnTUs 554/566 ng/L and an echocardiogram that showed dilated right chambers, hypertrophy and global hypokinesia of the left ventricle, increased filling pressures of the left ventricle and pulmonary hypertension. Myocarditis associated with pembrolizumab was suspected, so high dose steroids were initiated and endomyocardial biopsy was conducted, resulting in iatrogenic cardiac tamponade. To determine the etiology of the suspected myocarditis, an endomyocardial biopsy was performed. Unfortunately, an intraprocedural complication arose: pleural effusion resulting in iatrogenic cardiac tamponade, leading to hemodynamic instability. It required immediate pericardial drainage via subxiphoid puncture, obtaining a 550 mL hematic debit. Clinical manifestations raised suspicion of tamponade, prompting a bedside echocardiogram for a definitive diagnosis. Despite these efforts, the patient remained hemodynamically unstable, and due to the elevated surgical risk, intrapericardial thrombin was employed to achieve successful hemostasis.ConclusionsCardiac tamponade is a life-threatening condition that can sometimes be induced iatrogenically, resulting from percutaneous interventions. Despite limited evidence regarding this therapeutic strategy, in patients experiencing iatrogenic cardiac tamponade with hemodynamic instability and high surgical risk, the administration of intra-pericardial thrombin could be contemplated.

Medium-Term Outcomes of Stent Therapy for Aortic Coarctation in Children Under 30 kg with New Generation Low-Profile Stents: A Follow-Up Study of a Single Centre Experience

We previously reported short-term outcomes for stenting of aortic coarctation (CoA) (native or re-coarctation) with newer generation low-profile stents (Valeo, Formula, and Begraft stents) in children under 30 kg. We present here the medium-term outcomes of this procedure. Retrospective review of patients weighing under 30 kg who had percutaneous stent treatments for coarctation between 2012 and 2021 was performed. Clinical and procedural data were collected; 19 patients were included. The median age at the time of procedure was 5.1 [4.1–6.4] years and median weight 21.0 [17.3–22.3] kg. One patient had a history of re-coarctation. Thirteen (68%) patients were on anti-hypertensives pre-procedure. Different types of stents were used (14 Valeo™, 4 Formula® 535, 1 BeGraft), which can all be dilated to 18 mm or larger. One patient required a 9 F sheath, all others required a 7 F sheath. The narrowest diameter in the aorta increased from a median of 3.5 [3.0–4.5] to 9.4 [8.9–9.8] mm, p < 0.001; there was a reduction in the median pressure gradient across the coarctation from 35.0 [30.0–43.0] to 5.0 [0–10.0] mmHg, p < 0.001. There were no intra-procedural complications. Follow-up was for a median of 56.0 [13.0–65.0] months. Five (26%) of patients underwent re-intervention after a median time frame of 40.0 [39.5–52.0] months; four had balloon dilation, one had repeat stent implantation. Five (26%) patients were on anti-hypertensive agent(s) post-intervention. Our single centre experience demonstrates that percutaneous stenting for coarctation of aorta in children under 30 kg, with low-profile stents, had no significant complications during the median follow-up time of 56 months. This study demonstrated that the procedure is safe and effective for short and medium-term therapy in this group of patients with a 26% re-intervention rate. A quarter of patients remained on anti-hypertensive medication post stenting, emphasizing the importance of long-term follow-up.

Abstract WP124: Dual Energy Head CT Immediately Following Mechanical Thrombectomy Rarely Leads to Changes in Clinical Management

Introduction: No guidelines exist regarding imaging after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Dual Energy Head CT (DECT) can differentiate between contrast staining and intracranial hemorrhage (ICH). We obtained routine DECT for AIS patients immediately following MT. We aimed to understand the impact of DECT on clinical management. Methods: We conducted a single-center retrospective study of AIS patients who underwent MT and immediate post-procedure DECT between March 2021 and February 2023. Patients were grouped by whether or not DECT results changed management, compared to our standard post-thrombectomy protocol and as documented in clinical notes. Continuous variables were compared using Wilcoxon Rank-Sum tests, and categorical variables were compared using Chi-square tests. Results: Of 173 patients who met inclusion criteria, 13 (7.5%) had documented changes in management following DECT. Management changes included delayed anti-thrombotic administration, lowered systolic blood pressure goals, and serial imaging. There were no statistically significant differences in age, gender, initial NIHSS, ischemic core size pre-MT, or treated vessel between patients with and without a change in management. Patients with management changes were more likely to have had procedural complications, contrast staining, any ICH, and symptomatic ICH (Table). While 34 patients had ICH on DECT, this only led to a documented change in management for 11 (32.4%) patients. Conclusion: Routine DECT immediately after MT rarely changed clinical management. Immediate DECT may be reserved for patients with intraprocedural complications or those with clinical suspicion of ICH.

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.

Comparison of PED/PED Flex and PED Shield in the treatment of unruptured intracerebral aneurysms.

The object of this study was to compare the efficacy and safety profile of the Pipeline embolization device (PED)/Pipeline Flex embolization device (PED Flex) with that of the Pipeline Flex embolization device with Shield Technology (PED Shield). After introducing the first-generation PED and the second-generation PED Flex with its updated delivery system, the PED Shield was launched with a synthetic layer of phosphorylcholine surface modification to reduce thrombogenicity. This is a retrospective review of unruptured aneurysms treated with PED/PED Flex versus PED Shield between 2017 and 2022 at the authors' institution. Patients with ruptured aneurysms, adjunctive treatment, failed flow diverter deployment, and prior treatment of the target aneurysm were excluded. Baseline characteristics were collected for all patients, including age, sex, past medical history (hypertension, hyperlipidemia, diabetes mellitus), smoking status, aneurysm location, and aneurysm dimensions (neck, width, height) and morphology (saccular, nonsaccular). The primary outcome was procedural and periprocedural complication rates. The study cohort comprised 200 patients with 200 aneurysms, including 150 aneurysms treated with the PED/PED Flex and 50 treated with the PED Shield. With respect to intraprocedural and periprocedural complications, length of stay, length of follow-up, and functional outcome at discharge, there was no significant difference between the two cohorts. At the midterm follow-up, the rate of in-stent stenosis (PED/PED Flex: 14.2% vs PED Shield: 14.6%, p = 0.927), aneurysm occlusion (complete occlusion: 79.5% vs 80.5%, respectively; neck remnant: 4.7% vs 12.2%; dome remnant: 15.7% vs 7.3%; p = 0.119), and the need for retreatment (5.3% vs 0%, p = 0.097) were comparable between the two cohorts. This study suggests that, as compared to first- and second-generation PED and PED Flex, the third-generation PED Shield offers similar rates of complications, aneurysm occlusion, and in-stent stenosis at the midterm follow-up.