Ipsilateral Stenosis Research Articles

Cephalic to jugular vein bypass surgery of subclavian vein stenosis for arteriovenous fistula salvage in maintenance hemodialysis patients.

Ipsilateral subclavian vein stenosis in a well-functioning upper extremity arteriovenous fistula (AVF) is a significant factor contributing to AVF failure and sometimes swelling of ipsilateral upper extremity. Graft bypass surgery can alleviate outflow tract stenosis in upper extremity AVF, restore function, and efficiently relieve arm swelling. The present study aimed to evaluate patency and postoperative complications after cephalic to jugular graft bypass surgery in patients with upper extremity AVF failure or upper extremity swelling on the same side of the AVF resulting from ipsilateral subclavian vein stenosis. Five patients with upper extremity AVF and ipsilateral subclavian vein stenosis undergoing maintenance hemodialysis were included. Three patients had AVF dysfunction, while two experienced swelling of the arm due to high venous pressure in the AVF. The surgical procedure involved creating a subcutaneous tunnel in the shoulder to connect a 6 mm polytetrafluorethylene (PTFE) graft, from either near the fistula site (n = 3) or at the mid-upper arm cephalic vein (n = 2), to the jugular vein. Graft bypass surgery was successful, and all patients were able to resume hemodialysis postoperatively. Upper extremity edema improved, without any postoperative wound infections, non-healing wounds, steal syndrome, or high-flow AVF leading to heart failure as a complication. Five to 19 months after surgery, the bypass grafts exhibited a primary patency rate of 100%, and vascular access fulfilled the requirements for hemodialysis. Cephalic to jugular vein bypass surgery for upper extremity AVF with ipsilateral subclavian vein stenosis effectively preserved function of the original fistula, and was associated with few postoperative complications.

RNF213 p.Arg4810Lys Variant Is Associated with Higher Stenosis Progression in Asymptomatic Intracranial Artery Stenosis.

Intracranial artery stenosis (ICAS) is a significant contributor to ischemic stroke, with the RNF213 p.Arg4810Lys variant identified as a related genetic factor. We explored the clinical outcomes of the RNF213 genotype in patients with asymptomatic ICAS. Between November 2011 and March 2019, 139 patients with asymptomatic ICAS were enrolled in this study. Genotyping for RNF213 p.Arg4810Lys was performed using Sanger sequencing. A comprehensive analysis was conducted to compare the RNF213 genotype with background characteristics and clinical outcomes such as ipsilateral ischemic cerebrovascular events and stenosis progression. RNF213 p.Arg4810Lys was found in 25% of cases, revealing distinct clinical features between carriers and non-carriers. The incidence of ipsilateral ischemic cerebrovascular events was 4.3% (6/139 cases), and stenosis progression was observed in 13% (18/139 cases) during a mean follow-up period of 58months. Stenosis progression rates were notably higher in the RNF213 variant group (25.7%; 9/35 cases) than in the RNF213 wild-type group (8.7%; 9/104 cases). Cumulative stenosis progression rate was significantly higher in the RNF213 variant group than in the RNF213 wild-type group (log-rank test, P = 0.0004). Multivariate Cox regression analysis indicated a significant association between the RNF213 p.Arg4810Lys variant and an increased risk of stenosis progression (P = 0.03, odds ratio 3.2; 95% confidence interval, 1.1-9.0). The RNF213 p.Arg4810Lys variant exhibits clinical disparities in asymptomatic ICAS and is notably linked to a heightened risk of stenosis progression. These results suggest a distinct difference in the vascular stenosis mechanism associated with this variant, warranting further investigation into its clinical implications and potential mechanistic insights.

Recruitment of pial collaterals and carotid occlusive disease in large-vessel occlusion ischemic stroke.

Despite the fundamental role of pial collateral vessels in limiting the progression of ischemic tissue injury in acute stroke with large vessel occlusion (LVO), in addition to the fact that collateral vessel abundance varies naturally from person to person for genetic reasons, there is limited knowledge regarding potential factors contributing to inherent interindividual variation in pial collateral supply. As it has been repeatedly hypothesized that chronic carotid occlusive disease may favor pial collateralization, we aimed to investigate the association between quantitatively assessed leptomeningeal collateral supply and pre-existing carotid stenosis in patients with acute stroke due to LVO. Patients with proximal middle cerebral artery (MCA) occlusion with or without additional internal carotid artery (ICA) occlusion were included. The degree of collateral supply was quantitatively assessed based on signal variance in T2*-weighted time series in perfusion-weighted magnetic resonance imaging (PWI). Patients were stratified into two groups according to quantitative collateral status (poor and fair to good collateral supply). The prevalence of high-grade ICA stenosis (≥70%) was evaluated in both groups. A total of 98 patients (mean age 68.8 ± 16.1 years, n = 52 (53.1%) of whom were female individuals) with MCA and/or ICA occlusion were included in the final analysis. Out of these patients, 42 had poor collateral supply, while 56 exhibited fair to good collateral supply. Additionally, 18 patients showed ipsilateral high-grade ICA stenosis. After classifying the entire cohort based on their collateral status (poor vs. fair to good collateral supply), there was no significant difference in the proportion of the patients with ipsilateral high-grade ICA stenosis between the two groups. Specifically, 6 (14.3%) patients had poor collateral supply, and 12 (21.1%) patients had fair to good collateral supply. The odds ratio (OR) was 1.58, with a 95% confidence interval (CI) of 0.490-5.685 and the p-value of 0.440. In the entire patient cohort, signal variance-based collateral supply was significantly correlated with initial stroke severity (r = -0.360, p < 0.001), baseline ischemic core volume (r = -0.362, p < 0.001), and functional outcomes (score on the modified Rankin Scale) at discharge (r = -0.367, p < 0.01). In this study, we performed a quantitative and observer-independent MRI-based collateral assessment in patients with LVO. We found no significant difference in the prevalence of pre-existing high-grade ICA stenosis between patients with fair to good collateral supply and those with poor collateral supply. The potential influence of demographic and clinical variables on pial collateral supply in patients with acute stroke warrants further exploration in future studies. MRI-based collateral supply is significantly related to initial stroke severity, ischemic core volume, and early functional outcomes.

A case report on the choice of venous access after ectopic peripherally inserted central catheter in an upper limb of a patient with a second recurrence of right-side breast cancer.

Intravenous catheter placement in the healthy upper extremity is preferred for chemotherapy in patients with breast cancer. Common venous accesses are peripherally inserted central catheters (PICCs) and totally implantable intravenous port catheters (TIVPs). In this case, a patient with breast cancer had a history of infusion port placement through the left internal jugular vein, with ipsilateral innominate vein stenosis after placement. The patient was re-treated with a PICC placed ectopically through the left upper limb into the intrathoracic vein. After multidisciplinary consultation, a transfemoral PICC combined with intracavitary electrocardiography (IC-ECG) was performed to establish venous access. This case can assist PICC catheterization nurses in developing optimal venous access strategies tailored to the specific situations of patients in similar situations. Through adequate evaluations and optimal selection of venous access, the success rate of disposable catheterization can be improved, and the risk of complications reduced. A 53-year-old female with breast cancer had a history of infusion port, with ipsilateral innominate vein stenosis after placement. The patient was re-treated with a PICC placed ectopically through the left upper limb into the intrathoracic vein. An axial computed tomography (CT) image before totally implantable venous access port (TIVP) placement and An axial CT 103 days after TIVP placement shows diffuse stenosis of the left innominate vein, associated with infusion port placement through the left internal jugular vein. After multidisciplinary consultation, a transfemoral PICC combined with intracavitary electrocardiography (IC-ECG) was performed to establish venous access. The patient's lower limb PICC was left in place for 201 days with no complications, completing the full treatment cycle. This case presents a rare and insightful clinical scenario. For patients with a history of infusion port placement, particularly via the left internal jugular vein, careful analysis of the innominate vena cava and examination of chest wall vein exposure are essential to determining the optimal vascular access strategy.

Outcomes following carotid revascularization in patients with prior ipsilateral carotid artery stenting in the Vascular Quality Initiative

ObjectiveThe outcomes of carotid revascularization in patients with prior carotid artery stenting (CAS) remain understudied. Prior research has not reported the outcomes after transcarotid artery revascularization (TCAR) in patients with previous CAS. In this study, we compared the peri-operative outcomes of TCAR, transfemoral CAS (tfCAS) and carotid endarterectomy (CEA) in patients with prior ipsilateral CAS using the Vascular Quality Iniatitive. MethodsUsing Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA after prior ipsilateral CAS. We included covariates such as age, race, sex, body mass index, comorbidities (hypertension, diabetes, prior coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, renal dysfunction, smoking, chronic obstructive pulmonary disease, and anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality, and cranial nerve injury (CNI) after TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing. ResultsWe identified 2137 patients undergoing revascularization after prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%), and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%; adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.11-1.05; P = .06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%; aOR, 0.80; 95% CI, 0.16-3.98; P = .8). Compared with CEA, TCAR was associated with lower odds of postoperative MI (0.1% vs 14%; aOR, 0.02; 95% CI, 0.00-0.10; P < .001), stroke/death/MI (0.8% vs 15%; aOR, 0.05; 95% CI, 0.01-0.25; P < .001), and CNI (0.1% vs 3.8%; aOR, 0.04; 95% CI, 0.00-0.30; P = .002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1%, with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (P < .001). ConclusionsIn asymptomatic patients with prior ipsilateral CAS, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably higher in-hospital stroke/death rates. In line with the postprocedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.

Determinants of prehospital and in-hospital delay in patients with symptomatic carotid stenosis and their influence on the outcome after elective carotid endarterectomy

BackgroundThis study analyses the determinants of prehospital (index event to admission) and in-hospital delay (admission to carotid endarterectomy (CEA)). In addition, the analysis addresses the association between prehospital or in-hospital...

Dynamic internal jugular vein venography: a descriptive study in 89 patients with suspected cerebral venous outflow disorders

BackgroundInternal jugular vein (IJV) stenosis has recently been recognized as a plausible source of symptom etiology in patients with cerebral venous outflow disorders (CVD). Diagnosis and determining surgical candidacy remains...

First-Line Treatment of Symptomatic Subocclusive Large-Vessel Stroke: Results of a Nationwide StrokeNet Survey.

Limited evidence is available for the treatment of acute symptomatic sub-occlusive lesions in ischemic stroke. We sought to identify current treatment patterns of stroke teams at academic health centers. We conducted an email survey of the National Institutes of Health (NIH) StrokeNet regional coordinating centers (RCCs). Each RCC principal investigator (PI) was asked to nominate a local stroke interventionalist, or neurologist if the RCC PI was an interventionalist, most aligned with the typical practice pattern of the RCC's lead hospital, to receive a survey. The survey consisted of a clinical vignette and displayed a sub-occlusive lesion in the left middle cerebral artery on CT angiogram followed by subsequent scenarios, revising only one historical, clinical, or radiographic variable at a time. Participants were asked to select initial management for each scenario. Results were reviewed and analyzed by stroke-trained physicians. Responses were received from 42 (77.8%) of 54 surveyed individuals, representing 25 (92.6%) of 27 RCCs nationwide, including 25 (59.5%) interventionalists. The majority (76.2%) of respondents treated the patient in the primary clinical vignette with mechanical thrombectomy (MT). Among all six clinical scenarios, respondents chose MT with or without medical management as first-line treatment for four (67%) vignettes. Exceptions were low NIH Stroke Scale and known ipsilateral stenosis, where respondents chose medical management as first-line treatment. Despite limited evidence to support MT versus other treatment strategies, the majority of StrokeNet RCCs respondents would use MT with or without medical therapy to treat AIS due to intracranial sub-occlusive lesions.

The Association Between Cervical Foraminal Stenosis and Adhesive Capsulitis: An Imaging-based Case-Control Study.

Retrospective single-center imaging-based case-control study. To determine the association between cervical foraminal stenosis and adhesive capsulitis. Patients with cervical spondylosis often exhibit shoulder symptoms. Cervical radiculopathies, particularly C5, can cause severe shoulder pain and reduced shoulder mobility, mimicking glenohumeral adhesive capsulitis (frozen shoulder), a common shoulder condition. This is the first study investigating the connection between adhesive capsulitis and cervical radiculopathy. 438 patients who underwent glenohumeral hydrodistension between 2012 and 2019 were reviewed. Included were individuals with unilateral frozen shoulder investigated using ultrasound and cervical spine MRI to investigate cervical spondylosis. Foraminal stenosis at C3/4, C4/5, C5/6 and C6/7 was graded in axial T2 MRI, ipsilateral and contralateral to the adhesive capsulitis. The presence of foraminal stenosis ipsilateral to the frozen shoulder (cases) was compared with the contralateral side (control). McNemar's exact test was used to assess the strength of a correlation. Among 438 patients, 107 reported frozen shoulder and neck pain (24.5%), with 48 matching the study criteria. A significant association between ipsilateral frozen shoulder and C4/5 foraminal stenosis was observed (P=0.00000008636). Ipsilateral foraminal stenosis was observed in 57.3% of these cases, with bilateral stenosis in 29.1%. Additionally, 78% had neck pain on the same side as their frozen shoulder, and 44% had pain radiating to the shoulder. 48% patients underwent nerve-targeted interventions, with 44% addressing the C5 nerve (25% C5 steroid injection and 19% C4/5 anterior cervical discectomy and fusion). A substantial association between C5 foraminal stenosis and ipsilateral frozen shoulder was found. C5 radiculopathy could be a risk factor for "neurogenic frozen shoulder". Those diagnosing frozen shoulder and cervicobrachialgia should recognize that frozen shoulder and C5 radiculopathy may coexist. A multidisciplinary approach involving both shoulder and spine specialists is recommended for a definitive diagnosis.

Association between Asian race and perioperative outcomes after carotid revascularization varies with Asian procedure density

ObjectivePostoperative outcomes following carotid revascularization are understudied in Asian patients. We aimed to assess whether disease severity and postoperative outcomes following carotid revascularization differ between Asian and White patients, and whether this varies with Asian procedure density. MethodsWe analyzed the Vascular Quality Initiative Carotid Endarterectomy and Carotid Artery Stenting datasets from 2003 to 2021. Regions were divided into tertiles based on Asian procedure density. Propensity scores were used to match Asian and White patients based on patient factors and procedure type. The primary outcome variable was a collapsed composite of in-hospital ipsilateral stroke/death/myocardial infarction. χ2 tests were used to assess association between Asian race and disease severity, center and surgeon volume, and 1-year outcomes. Logistic and Cox regressions were performed between the matched cohorts. ResultsA total of 1766 Asian and 159,608 White patients underwent carotid revascularization, and we identified 2704 patients (1352 Asian and 1352 White) in the matched cohorts. Among propensity matched patients, all-comer Asian patients more commonly had >80% ipsilateral stenosis (63% vs 52%; P < .001) and a moderate/severe preoperative Rankin score (7.6% vs 5.1%; P = .007). The rate of in-hospital stroke/death/myocardial infarction was higher in Asian patients (2.6% vs 1.3%; P = .012), and this disparity was more pronounced in the lowest tertile of Asian procedure density (4.3% vs 0.5%; P < .001). Logistic regression in the propensity-matched cohort demonstrated Asian race was associated with lower odds of intervention at highest volume centers (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.2-0.3; P < .001) and by highest volume surgeons (OR, 0.3; 95% CI, 0.3-0.4; P < .001). Asian race was associated with higher odds of in-hospital stroke/death/myocardial infarction (OR, 2.0; 95% CI, 1.1-3.8; P = .031), and there was a significant interaction between Asian procedure density and the relationship between Asian race and this outcome (interaction P = .001). After accounting for center and surgeon volume, the association of Asian race and the composite outcome was mitigated (OR, 1.5; 95% CI, 0.7-3.3; P = .300). Cox regression between the matched cohorts demonstrated that Asian race was associated with lower 1-year mortality (hazard ratio, 0.5; 95% CI, 0.3-0.7; P = .001) and higher risk of 1-year reintervention (hazard ratio, 16; 95% CI, 1.8-142; P = .013). ConclusionsAsian patients are more likely to present with a higher degree of carotid stenosis, higher preoperative risk, and experience worse perioperative outcomes. The association of Asian race with perioperative stroke/death/myocardial infarction varies with Asian procedure density and is also confounded by center and surgeon volume. These results highlight the importance of understanding referral patterns and cultural effects on outcomes disparities in Asian patients.

Age-specific sex-differences in cerebral blood flow velocity in relation to haemoglobin levels.

Cerebral blood flow (CBF) declines with age and abnormalities in CBF are associated with age-related cerebrovascular disease and neurodegeneration. Women have higher CBF than men, although this sex-difference diminishes to some extent with age in healthy subjects. The physiological drivers of these age/sex differences are uncertain, but might be secondary to age and sex-differences in haemoglobin (Hb) level. Hb levels are inversely correlated with CBF, are lower in women, and decline with age in men, but the interrelations between these factors have not been explored systematically either in healthy subjects or across the full age-range in patients with vascular risk factors. We aimed to determine the age-specific interrelations between sex, Hb, and CBF velocity in a large cohort of patients with cerebrovascular disease. In patients with a recent transient ischaemic attack or minor stroke (Oxford Vascular Study) and no ipsilateral or contralateral stenosis of the carotid or intracranial arteries, we related peak-systolic velocity (PSV) and other parameters on transcranial Doppler ultrasound (TCD) of the middle cerebral artery to sex, age, Hb and vascular risk factors. Of 958 eligible subjects (mean age/SD = 68.04/14.26, 53.2% male), younger women (age < 55 years) had higher CBF velocities than men (mean sex difference in PSV at age < 55 years = 16.31 cm/s; p < 0.001), but this difference declined with age (interaction p < 0.001), such that it was no longer significant at age 75-84 (∆PSV = 3.26 cm/s; p = 0.12) and was reversed at age ⩾ 85 (∆PSV = -7.42 cm/s; p = 0.05). These changes mirrored trends in levels of Hb, which were higher in men at age < 55 (∆Hb = 1.92 g/dL; p < 0.001), but steadily decreased with age in men but not in women (interaction p < 0.001), with no residual sex-difference at age ⩾ 85 (∆Hb = 0.12 g/dL; p = 0.70). There was an inverse correlation between Hb and PSV in both women and men (both p ⩽ 0.01), and the sex-difference in PSV at age < 55 was substantially diminished after adjustment for Hb (∆PSV = 6.92; p = 0.036; ∆PSV = 5.92, p = 0.13 with further adjustment for end-tidal CO2). In contrast, the sex difference in PSV was unaffected by adjustment for systolic and diastolic blood pressure, heart rate, and vascular risk factors (history of hypertension, diabetes, hyperlipidaemia and smoking). CBF velocity is strongly correlated with Hb level at all ages, and sex-differences in CBF velocity appear to be explained in major part by age-related sex-differences in Hb.

Association of Carotid Artery Disease with Collateralization and Infarct Growth in Patients with Acute Middle Cerebral Artery Occlusion.

Collaterals are important in large vessel occlusions (LVO), but the role of carotid artery disease (CAD) in this context remains unclear. This study aimed to investigate the impact of CAD on intracranial collateralization and infarct growth after thrombectomy in LVO. All patients who underwent thrombectomy due to M1 segment occlusion from 01/2015 to 12/2021 were retrospectively included. Internal carotid artery stenosis according to NASCET was assessed on the affected and nonaffected sides. Collaterals were assessed according to the Tan score. Infarct growth was quantified by comparing ASPECTS on follow-up imaging with baseline ASPECTS. In total, 709 patients were included, 118 (16.6%) of whom presented with CAD (defined as severe stenosis ≥70% or occlusion ipsilaterally), with 42 cases (5.9%) being contralateral. Good collateralization (Tan 3) was present in 56.5% of the patients with ipsilateral CAD and 69.1% of the patients with contralateral CAD. The ipsilateral stenosis grade was an independent predictor of good collateral supply (adjusted OR: 1.01; NASCET point, 95% CI: 1.00-1.01; P = .009), whereas the contralateral stenosis grade was not (P = .34). Patients with ipsilateral stenosis of ≥70% showed less infarct growth (median ASPECTS decay: 1; IQR: 0-2) compared with patients with 0%-69% stenosis (median: 2; IQR: 1-3) (P = .005). However, baseline ASPECTS was significantly lower in patients with stenosis of 70%-100% (P < .001). The results of a multivariate analysis revealed that increasing ipsilateral stenosis grade (adjusted OR: 1.0; 95% CI: 0.99-1.00; P = .004) and good collateralization (adjusted OR: 0.5; 95% CI: 0.4-0.62; P < .001) were associated with less infarct growth. CAD of the ipsilateral ICA is an independent predictor of good collateral supply. Patients with CAD tend to have larger baseline infarct size but less infarct growth.

Abstract 237: Thrombectomy is the Leading Treatment Modality for Symptomatic Sub‐Occlusive Lesions: a Nationwide StrokeNet Survey

Introduction Approximately 3% of all acute ischemic stroke are caused by sub‐occlusive thrombi in the proximal intracranial vasculature. There is a paucity of evidence regarding optimal treatment of this stroke etiology, with most evidence derived from retrospective case series preceding the advent of mechanical thrombectomy. We sought to survey the National Institute of Health StrokeNet to determine real‐world treatment patterns in experienced stroke centers. We hypothesized that most providers would choose mechanical thrombectomy (MT) over medical management (MM). Methods We conducted an email survey of all StrokeNet regional coordinating centers (RCCs). Each RCC principal investigator (PI) was asked to provide a name of a local stroke endovascular specialist most aligned with their region’s typical practice pattern. A subsequent survey was sent to each if the StrokeNet RCC PIs and their nominated interventionalists. Questions were based on a clinical vignette accompanied by CT angiogram displaying a sub‐occlusive lesion in the left middle cerebral artery (MCA) (Figure 1a). Subsequent questions kept the same basic vignette, changing only one historical, clinical, or radiographic variable at a time. Participants were asked to describe initial management for each scenario. If more than one initial treatment was selected, or if no treatment option was selected, applicants were asked to please explain. Results were gathered from each participant using Google Forms. Results Among 27 StrokeNet RCCs, 25 (93%) provided at least one response; responses were received from 43 of 54 (80%) physicians surveyed, including 26 stroke interventionalists. A total of 4 sites selected an alternate responder of the appropriate specialty if their PI or chosen representative was unable to respond. The majority (71.4%) of respondents treated patients with acute sub‐occlusive thrombus with MT (Figure 1b). MT alone, or MT with additional MM, comprised the majority of responses to clinical vignette variation questions[Moderate core (ASPECTS 6): 71.4% MT, 76.2% MT with MM; Last Known Normal 12‐hours prior with Favorable Advanced Imaging: 73.8% MT, 83% MT with MM; Last Known Normal 12‐hours prior without Advanced Imaging: 54.8% MT, 64.3% MT with MM; Severe hypertension (210/110mmHg): 50% MT, 69% MT with MM; Poor Collaterals: 71.4% MT, 78.6% MT with MM]. Only two scenarios, low baseline National Institutes of Health Stroke Score (NIHSS) and history of ipsilateral stenosis, led respondents to favor non‐thrombectomy approaches (Low NIHSS (3): 9.5% MT; History of Ipsilateral Stenosis: 30.9% MT, 47.6 MT with MM) (Figure1c‐d). Conclusion Despite limited evidence to support MT versus other treatment strategies, the majority of StrokeNet Regional Coordinating Center sites would use MT to treat acute strokes due to intracranial sub‐occlusive thrombi.

A Novel Window Into Human Vascular Remodeling and Diagnosing Carotid Flow Impairment: The Petro-Occipital Venous Plexus.

Background Adaptive arterial remodeling caused by flow reduction from downstream stenosis has been demonstrated in animal studies. The authors sought to determine whether inward remodeling from downstream stenosis also occurs in humans and is detectable by ex vacuo expansion of the Rektorzik venous plexus (RVP) surrounding the petrous internal carotid artery. Methods and Results The authors analyzed 214 intracranial magnetic resonance imaging examinations that included contrast-enhanced vessel wall imaging. RVP symmetry was qualitatively assessed on vessel wall imaging. RVP thickness (RVPT) was measured on the thicker side if asymmetric or randomly assigned side if symmetric. Maximum stenosis (M1 or intracranial internal carotid artery) was measured. Posterior communicating artery and A1 diameters (>1.0 mm and 1.5 mm, respectively) defined adequate collateral outflow when proximal to the stenosis. Seventy-two patients had stenosis downstream from RVPT measurements. For those without adequate outflow (38 of 72), 95.0% with RVPT ≥1.0 mm had ≥50% stenosis compared with only 5.6% with RVPT <1.0 mm. For these 72 patients, higher RVPT (RVPT ≥1.0 mm versus <1.0 mm) and absent adequate outflow were associated with greater downstream stenosis (P<0.001) using multivariate regression. For patients with downstream stenosis without adequate outflow, asymmetric RVP thickening was associated with greater ipsilateral stenosis (P<0.001, all had ≥46% stenosis) when stenosis was unilateral and greater differences in stenosis between sides (P=0.005) when stenosis was bilateral. Conclusions Inward internal carotid artery remodeling measured by RVPT or RVP asymmetry occurs as downstream stenosis approaches 50%, unless flow is preserved through a sufficiently sized posterior communicating artery or A1, and may serve as a functional measure of substantial flow reduction from downstream stenosis.

Can Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios Predict the Risk of Developing New Ischemic Lesions After Carotid Stenting?

Aim: It has been reported that the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are associated with carotid artery stenosis rate, risk of restenosis after stenting, and clinical outcome after an ischemic stroke, and are also predictive markers. The objective of this study is to evaluate whether NLR and PLR values and the associated temporal changes are indicators of the risk for newly developing ischemic lesions. Material and Methods: Patients who underwent stenting in our clinic between November 2019 and January 2022 and who had a complete blood count and a diffusion magnetic resonance imaging scan before and after the procedure, were included in the study and evaluated in two groups; patients with and without newly developing ischemic lesions. Results: Newly developing ischemic lesions were detected in 27 of the 50 patients included in the study. There was no difference in baseline and 48th-hour NLR and PLR rates and the temporal variation of these rates between patients with and without newly developing ischemic lesions. Erythrocyte distribution width (RDW) and hemoglobin (HGB) values were higher in the without newly developing ischemic lesions group at 48 hours, but there was only a significant difference between the RDW temporal change between the two groups. In the correlation analysis, no significant correlation was found between NLR, PLR, and their temporal changes, ipsilateral and contralateral stenosis rates, age, and residual stenosis rates. Conclusion: There was no significant relationship between the development of newly developing ischemic lesions and NLR and PLR values and the associated temporal changes.

Length of Carotid Plaque Impacts Retinal Microvascular Densities of Carotid Artery Stenosis Patients.

We explored the retinal microvascular changes in carotid artery stenosis (CAS) and their relationship with carotid plaque morphology. All participants were diagnosed with carotid artery stenosis by a neurologist. Participants underwent digital subtraction angiography (DSA) and optical coherence tomography angiography (OCTA) imaging. The degree and length of carotid plaque were obtained from the DSA tool. OCTA tool measured the densities in the superficial vascular complex (SVC) and deep vascular complex (DVC). One hundred seventeen patients with CAS patients were included in our data analysis. Eyes with ipsilateral stenosis had reduced retinal microvascular densities when compared to contralateral eyes in patients with CAS (P = 0.016 for SVC, and P = 0.004 for DVC). Microvascular densities correlated with the length of carotid plaque (P = 0.015 for SVC, and P = 0.022 for DVC) in our CAS cohort, although they did not correlate with the degree of carotid plaque (P = 0.264 for SVC, and P = 0.298 for DVC). However, when stratified into moderate and severe subgroups, the degree of carotid plaque correlated with microvascular densities in patients with severe stenosis (P = 0.045 for SVC, and P = 0.038 for DVC). Our study suggests that OCTA can noninvasively detect retinal microvascular changes in patients with CAS and that these changes correlated with the length of the stenosis, but future studies are required to confirm these findings. Noninvasive and rapid acquisition of the OCTA image might have the potential to be used as a screening tool to detect microvascular changes in carotid artery stenosis.

The Positional Relationship between Lacunae and White Matter Hyperintensity in Patients with Cerebral Small Vessel Disease.

Lacunae and white matter hyperintensity (WMH) are two crucial imaging biomarkers of cerebral small vessel disease (CSVD). Multiple studies have revealed a close relationship between WMH and lacunae and found that a double penumbra existed at the edge of WMH that affects lacunae formation. The study aimed to explore the spatial distribution characteristics and possible influencing factors of lacuna in relation to white matter hyperintensity in patients with CSVD. A total of 480 CSVD patients with WMH and with or without lacunae were included. Data about blood biochemical indicators, cerebrovascular CT angiography, 24-hour ambulatory blood pressure and ambulatory electrocardiogram, brain magnetic resonance imaging, and transcranial Doppler ultrasound were gathered from all subjects. They were categorised into four groups based on the spatial interaction between lacunae and WMH. Univariate analyses and multiple logistic regression analyses were used to compare the differences in traditional vascular risk factors, heart rate and blood pressure indicators, arterial pulsatility index (PI) values, and arterial stenosis among different groups. The average age of 480 patients was (58.63 ± 11.91) years, with 347 males (72.3%). Univariate analysis indicated that age, fasting blood glucose, triglycerides, total cholesterol, highdensity lipoprotein, 24-hour and daytime and night systolic and diastolic blood pressure, nocturnal heart rate, heart rate variability, PI values of ipsilateral and contralateral MCA (middle cerebral artery) and ICA (Internal carotid artery) of the lacunae, Fazekas score of PWMH (periventricular white matter hyperintensities), the proportion of MCA or ICA with stenosis rate over 50% on the ipsilateral side of the lacunae were significantly different between different groups (p < 0.05). High fasting blood glucose (OR=1.632, 95% CI= (1.128, 2.361), p =0.009), (OR=1.789, 95%CI= (1.270, 2.520), p = 0.001), (OR=1.806, 95% CI= (1.292, 2.524), p =0.001) was identified as a risk factor for lacunae formation by logistic regression analysis. High fasting blood glucose can be considered a risk factor for lacunae formation in patients with WMH. The more severe the PWMH and the higher the nocturnal heart rate, the more likely the lacunae, as well as PWMH, overlap completely. Ipsilateral arteriosclerosis and stenosis are independent risk factors for no contact between lacunae and PWMH.

Risk Factors for Cerebral Hyperperfusion Syndrome following Carotid Revascularization

Cerebral hyperperfusion syndrome (CHS) is a rare but known complication of carotid revascularization that can result in severe postoperative disability and death. CHS is a well-described sequela of carotid endarterectomy (CEA) and, more recently, of transfemoral carotid artery stenting (TFCAS), but its incidence after transcarotid artery revascularization (TCAR) has not been delineated. The aims of this study were to determine the impact of procedure type (CEA versus TCAR versus TFCAS) on the development of CHS as well as to identify perioperative risk factors associated with CHS. The Society for Vascular Surgery Vascular Quality Initiative was queried for patients aged ≥18years who underwent CEA, TCAR, or TFCAS from 2015-2021. Emergent procedures were excluded. The primary outcome was postoperative development of CHS, defined as the presence of postoperative seizures, intracerebral hemorrhage due to hyperperfusion, or both. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with CHS. 156,003 procedures were included (72.7% CEA, 12.4% TCAR, and 14.9% TFCAS). The incidence of CHS after CEA, TCAR, and TFCAS were 0.15%, 0.18%, and 0.53%, respectively. There was no significant difference in risk of CHS after TFCAS compared to CEA (odds ratio [OR]: 1.21; 95% confidence interval [CI] 0.76-1.92; P=0.416), nor was there a difference between TCAR and CEA (OR: 0.91; 95% CI 0.57-1.45; P=0.691). Perioperative risk factors associated with an increased risk of CHS included previous history of transient ischemic attack or stroke (OR: 2.50; 95% CI 1.69-3.68; P<0.0001), necessity for urgent intervention within 48hr (OR: 2.03; 95% CI 1.43-2.89; P<0.0001), treatment of a total occlusion (OR: 3.80; 95% CI 1.16-12.47; P=0.028), and need for postoperative intravenous blood pressure medication (OR: 5.45; 95% CI 3.97-7.48; P<0.0001). Age, preoperative hypertension, degree of ipsilateral stenosis less than or equal to 99%, and history of prior carotid procedures were not statistically associated with an increased risk of CHS. Discharging patients on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker was associated with a decreased risk of developing CHS (OR: 0.47; 95% CI 0.34-0.65; P<0.0001). Compared with CEA, TCAR and TFCAS were not statistically associated with an increased risk of postoperative CHS. Patients with a previous history of transient ischemic attack or stroke, who require urgent intervention or postoperative intravenous blood pressure medication, or who are treated for a total occlusion are at a higher risk of developing CHS. Using an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker on discharge appears to be protective against CHS and should be considered for the highest risk patients.

#5918 ENDOVASCULAR CREATION OF AN ARTERIOVENOUS FISTULA (ENDOAVF) FOR HEMODIALYSIS ACCESS: A RETROSPECTIVE MONOCENTRIC EXPERIENCE

Abstract Background and Aims Functioning vascular access is an essential element for life-saving hemodialysis therapy. Surgical creation of a radiocephalic arteriovenous fistula (AVF) is the gold standard of vascular access for hemodialysis. However an endovascular approach to arteriovenous fistula creation (endoAVF) has increasingly gained acceptance over the last years as an alternative to the conventional surgical method. It offers a minimally invasive method for the formation of arteriovenous shunts and allows the creation of fistulas with minimal vessel trauma. There are currently two technologies available for this purpose, the Ellipsys Vascular Access System (Medtronic, Avenu Medical, San Juan Capistrano, Calif) and the Wavelinq endoAVF System (BD Medical, Franklin Lakes, NJ). At our centre (Careggi University Hospital, Florence), we developed an integrated service, based on a multidisciplinary approach between Interventional Radiology and Interventional Nephrology for percutaneous arteriovenous fistulas utilizing both Ellipsys and Wavelinq. We describe our experience with a case series of 39 patients, showing feasibility and outcome of this treatment option. Method Between December 2020 and January 2023 we created an endoAVF in 39 patients. Patients were suitable for the procedure after a pre-therapeutic ultrasound vascular mapping showed adequate brachial, radial and ulnar vessels and no ipsilateral central venous stenosis. After procedure, we performed a regular clinical and ultrasound monitoring. Therefore, we collected data regarding patient characteristics, initial technical success rate, number of access lost and number of endoAVF meeting primary and secondary patency. Results Of the total of 39 patients treated with endoAVF, 29 (74.3%) were male, with a mean age of 60.1 ± 33.9 years. The Wavelinq procedure was performed in 32 patients (82.0%) and the Ellipsys procedure in 7 patients (17.9%). Initial technical success was achieved in 38 (97.4%) cases, while in 1 case we had a primary failure of the fistula (Figure 1). Among these 38 patients, 4 (10.5%) were lost to follow-up because of death from other causes (3 patients) and because of kidney transplantation (1 patient), while 2 other patients (5.2%) have not required hemodialysys yet. Of the remaining 32 patients, we had 2 fistulas lost because of complications and a cumulative functional patency of 93.7% (30 fistulas), with a primary patency rate of 76% (23 fistulas). Conclusion The endoAVF appears to be feasible and safe for the creation of arteriovenous fistula suitable for hemodialysis access. Our data show an high functional cumulative patency of the endoAVF and a good primary patency, reducing the necessity of further interventions. Furthermore, in the prevalent hemodialysis population, the minimally invasive endovascular arteriovenous fistula procedure should help improving long wait times for vascular access creation. Further studies with more patients and multicentric data are needed to assess long-term outcomes.

Perioperative Outcomes After Carotid Revascularization in Asian Patients Varies With Asian Procedure Density

The nature of postoperative outcomes following carotid revascularization is understudied in Asian patients. We aimed to determine if there are disparities in disease severity and postoperative outcomes in Asian patients following carotid revascularization and whether this varies with procedure frequency in Asian patients. We analyzed the Society for Vascular Surgery Vascular Quality Initiative Carotid Endarterectomy and Carotid Artery Stenting datasets from 2003 to 2021. We divided regions into tertiles based on Asian procedure density. Propensity scores were used to match White and Asian patients based on age, sex, comorbidities, contralateral carotid occlusion, and procedure type. Logistic and Cox regressions were performed within the matched cohort. The primary outcome variable was in-hospital ipsilateral stroke/death/myocardial infarction and we also examined differences in disease severity, center and surgeon volume, and late outcomes. A total of 159,608 White and 1766 Asian patients underwent carotid revascularization and we identified 2704 patients in the matched cohort. On adjusted analysis, there was no difference in symptomatic disease rate between groups (35%). However, Asian patients more commonly presented with >80% ipsilateral stenosis (63% vs 52%; P < .001) and a moderate/severe preoperative Rankin score (7.6% vs 5.1%; P = .007), which did not vary with Asian procedure density. The rate of in-hospital stroke/death/myocardial infarction was higher in Asian patients (2.6% vs 1.3%; P = .012), and this disparity was more pronounced in the lowest tertile of Asian procedure density (4.3% vs 0.5%; P < .001). Logistic regression within the propensity-matched cohort demonstrated Asian race was associated with a decreased odds of care by highest volume centers and surgeons, which was largely consistent across tertiles of Asian procedure density (Table I). Asian race was associated with twofold greater odds of in-hospital stroke/death/myocardial infarction, which was driven by the lowest tertile regions of Asian procedure density. After clustering at surgeon and center level, the effect of Asian race was mitigated. Cox regression within the matched cohort demonstrated that Asian race was protective against late mortality, with no differences in 1-year stroke or reintervention-free survival (Table II). Asian patients are more likely to present with a greater degree of carotid stenosis, preoperative risk, and experience worse perioperative outcomes. The increased odds of perioperative stroke/death/myocardial infarction is driven by regions with low Asian procedure density and is also mediated by the volume of centers and surgeons with which Asian patients tend to undergo care. These results highlight the need to understand the social and cultural effects on outcomes disparities in Asian patients.Table ILogistical regression of outcomes in propensity-matched cohortAssociation With Asian RaceOR (95% CI; P)ORa (95% CI; P)In-hospital stroke/death/myocardial infarction2.1 (1.2-3.7; P = .014)1.4 (0.7-3.0; P = .354)Operation at highest volume centers0.2 (0.2-0.3; P < .001)--Operation with highest volume surgeons0.3 (0.3-0.4; P < .001)--CI, Confidence interval; OR, odds ratio.aLogistical regression with clustering at surgeon and center level. Open table in a new tab Table IICox regression of late outcomes in propensity-matched cohortAsian RaceHR (95% CI, P)Long-term mortality0.6 (0.4-0.9; P = .011)1-year stroke-free survival1.1 (0.3-3.9; P = .878)1-year reintervention-free survival5.0 (0.8-33.0; P = .091)HR, Hazard ratio; OR, odds ratio. Open table in a new tab