Ischemic Complications Research Articles

The clinical effect of flow-diverting stent for treatment of unruptured internal carotid artery small- and medium-sized wide-neck aneurysms

Objective: To study the feasibility of domestic flow diverter(TFD) for the treatment of unruptured internal carotid artery small- and medium-sized wide-neck aneurysms. Methods: This is a retrospective case series study.The study retrospectively evaluated consecutive 54 patients with unruptured intracranial small- and medium-sized wide-neck aneurysms treated with TFD in the Department of Cerebrovascular Disease,the Second Affiliated Hospital of Kunming Medical University between October 2019 and January 2024. There were 11 males and 43 females, and the age of patients was (54.9±9.6) years (range:36 to 74 years). There were 63 aneurysms in 54 patients,6 of which were tandem multiple small aneurysms. One case had saccular aneurysms of bilateral internal carotid artery. The maximum diameter of aneurysm was (4.1±0.8) mm (range: 1.5 to 10.0 mm).The ratio of the maximum diameter of the aneurysm to the neck width diameter was 1.3±0.4 (range:0.4 to 2.4). The surgical and follow-up data were collected. The aneurysm embolization rate at the immediate operation and follow-up,and the complications were analyzed. The degree of aneurysm embolization was evaluated using the O'Kelly-Marotta (OKM) grading system,with OKM grade D as complete occlusion and grade C and above (C1,C2,C3 and D) as successful occlusion. Clinical outcomes of all patients were evaluated by modified Rankin scale(mRS). Results: For 63 aneurysms, 48 aneurysms were treated with TFD alone,and 15 aneurysms were treated with a combination of TFD and coiling. The immediate postoperative successful occlusion rate was 14.3% (9/63) and the complete occlusion rate was 3.2% (2/63). Follow-up results were obtained for all of the patients. The follow-up time (M(IQR)) was 124 (182) days (range: 85 to 754 days). The time to aneurysm successful occlusion was 140.5 (151.5) days (range: 85 to 308 days). At final follow-up,the successful aneurysm occlusion rate was 68.3% (43/63) and the complete occlusion rate was 58.7% (37/63). The complete occlusion rate of the TFD group was 50.0% (24/48) and the TFD+coiling group was 13/15. All patients had no aneurysm rupture,ischemic complications and no recurrence of the aneurysm needed to retreatment during the intraoperative and follow-up period. A total of 3 mild haemorrhagic complications which were related to dual-antiplatelet agents. Twelve patients had asymptomatic mild-moderate stent stenosis. TFD covered 66 branch vessels totally. Only 6 branches were affected by the time of the last follow-up and none of the patients had relevant ischaemic symptoms. All of 54 patients were evaluated as mRS score<2 points at the last follow-up. Conclusion: Using TFD to treat internal carotid artery unruptured small and medium-sized wide-neck aneurysms can simplify the surgical procedure with low complication rate, which is a clinically optional treatment approach.

Safety and efficacy of Neuroform Atlas stent-assisted coiling for the treatment of distal intracranial aneurysms: A single-center experience

ObjectiveTo investigate the effectiveness, safety, and efficacy of Atlas stents in the treatment of distal intracranial aneurysms (IAs). MethodsWe retrospectively analyzed patients with IAs who underwent stent-assisted coiling (SAC) from January 2018 to January 2022 and divided them into two groups: distal IAs treated with Atlas SAC and wide-necked aneurysms in other locations treated with SAC. The clinical data, imaging data, and postoperative follow-up data for the two groups of patients during hospitalization were collected. ResultsFifteen patients were included in the distal IA group, and 332 patients were included in the non-distal IA group. The baseline data for the two groups of patients were compared, and significant differences in aneurysm locations, whether the aneurysm had ruptured, and the width of the aneurysm neck were found between the two groups. In the distal IA group, all stents were successfully placed and released during the operation. No aneurysm rupture occurred during the operation. Immediate postoperative digital subtraction angiography (DSA) showed complete embolization of the aneurysm in 10 patients. Ischemic complications occurred perioperatively in two patients. The postoperative follow-up showed a poor prognosis (modified Rankin scale (mRs) > 2) in three patients and aneurysm recurrence in one patient. No significant differences in the treatment effect, surgical complications, or follow-up results were found between the two groups. ConclusionIn this series, the use of Atlas SAC for the treatment of distal IAs was not associated with higher complication rates, and shows satisfactory long-term occlusion rates and follow-up results.

Pylorus-preserving pancreatoduodenectomy preserving blood supply for pancreatic cancer with a history of proximal gastrectomy and sigmoidectomy: a case report

BackgroundBlood supply to the remnant stomach should be preserved during pancreatectomy in patients with a history of gastrectomy. Moreover, ischemic complications should be considered when performing pancreatoduodenectomy in patients with celiac axis and superior mesenteric artery (SMA) stenosis. However, whether these surgical procedures can be safely performed remains unclear.Case presentationA 75-year-old man had a history of laparoscopic proximal gastrectomy (PG) with double-flap technique for gastric cancer and laparoscopic sigmoidectomy for sigmoid cancer treated 4 years ago. Follow-up computed tomography (CT) revealed an irregular nodular tumor measuring 13 mm in the pancreatic head. The patient was diagnosed with resectable pancreatic head cancer without lymph node metastasis (cT1cN0M0, cStageIA) according to the Union for International Cancer Control, 8th edition. As a standard pancreatic cancer treatment, two courses of preoperative chemotherapy with gemcitabine plus S-1 were administered. CT after preoperative chemotherapy identified no significant changes in tumor size but revealed SMA stenosis due to atherosclerosis. Blood flow to the left-sided colon was supplied from the middle colic artery via the SMA because of the past sigmoidectomy with inferior mesenteric artery detachment. Therefore, SMA stent placement was performed 1 day preoperatively. Subsequently, pylorus-preserving pancreatoduodenectomy (PPPD) was performed, preserving the remnant stomach with the right gastroepiploic (RGE) artery and vein. After resection, indocyanine green fluorescence imaging confirmed a good blood supply to the remnant stomach. The operation time was 467 min, and the blood lost was 442 mL. Histopathologically, the tumor was diagnosed as moderate adenocarcinoma and pT1cN0M0, Stage IA. The postoperative course was uneventful. The patient was discharged on postoperative day 23. S-1 as adjuvant chemotherapy was administered on postoperative day 63. The patient has been alive without recurrence for 7 months.ConclusionsWe performed PPPD preserving blood supply for pancreatic head cancer in a patient with benign SMA stenosis and a history of PG and sigmoidectomy. Blood supply was preserved through preoperative SMA stent placement and a surgical procedure preserving the RGE vessels. Furthermore, S-1 adjuvant chemotherapy was successfully initiated. These multimodal therapies contributed to a favorable clinical outcome.

Reduction in Synovitis Following Genicular Artery Embolization in Knee Osteoarthritis: A Prospective Ultrasound and MRI Study.

Genicular artery embolization (GAE) has demonstrated potential as a treatment for knee osteoarthritis by targeting inflammation and pain, although current evidence remains limited. This study used imaging biomarkers to objectively assess synovitis and possible ischemic complications following GAE. This was a prospective, single-center trial including participants with mild-to-moderate knee osteoarthritis. Ultrasound, contrast-enhanced (CE), and non-CE-MRI were performed two days before and one and six months after GAE. Ultrasound biomarkers included synovial hypertrophy, effusion, and Doppler activity. A combined effusion-synovitis score was assessed on non-CE-MRI, while CE-MRI allowed differentiation between synovium and effusion and was used to calculate whole-joint and local synovitis scores. The post-GAE MRIs were reviewed for ischemic complications. Seventeen participants (aged 43-71) were treated. Significant reductions were observed in ultrasound-assessed synovial hypertrophy and Doppler activity, as well as in CE-MRI local and whole-joint synovitis scores. While reductions in effusion were noted in both ultrasound and MRI, these changes did not reach statistical significance. At one month, MRI revealed three cases of nonspecific osteonecrosis-like areas, which resolved completely by six months. This study demonstrated a reduction in synovitis and no permanent ischemic complication following GAE in knee osteoarthritis. Larger studies with longer follow-up are needed to confirm the long-term efficacy and safety of the procedure.

SURG-12. CLINICAL OUTCOMES OF AWAKE SURGERY WITH INTRAOPERATIVE MRI FOR INSULAR GLIOMA

Abstract BACKGROUND Surgical resection of insular glioma remains challenging due to the complex functional involvement and the intricate vascularization of the insular lobe. We reviewed clinical outcomes of awake surgery with intraoperative MRI for insular glioma at our hospital. METHODS We retrospectively reviewed the records of 27 consecutive patients with insular gliomas who underwent surgical treatment between 2014 and 2024. The extent of resection (EOR), ischemic complication and Karnofsky Performance Status (KPS) at postoperative discharge were analyzed in the awake surgery (AS) group compared to the non-awake surgery (NAS) group. RESULTS There were basal ganglionic involvement (12 cases), Berger-Sanai zone III&amp;IV (10 cases), and I, II, III&amp;IV (6 cases). Surgical resection was performed in 24 cases (biopsy in 3 cases). Elective awake surgery: 18 cases (of which 5 were abandoned due to poor arousal); intraoperative MRI: 24 cases. Additional resection after intraoperative MRI review was performed in 10 cases. The followings were studied in 24 cases where surgical resection was performed. In characteristics, basal ganglionic involvement was significantly different (3 patients in AS group and 7 patients in NAS group, p=0.04). The mean EOR was 81.4% in AS group vs. 53.4% in NAS group (p=0.008). Ischemic complication rate on postoperative MRI was 15.4% (2 cases) in AS group and 9.1% (1 case) in NAS group; all of them had no permanent neurological symptoms. The deterioration of KPS at discharge was not found in both groups. CONCLUSION The clinical outcomes of insular glioma in awake surgery with intraoperative MRI in this study was comparable to those of the previous reports. It was indicated that awake surgery with intraoperative MRI contributes greatly to maximum safe resection for insular glioma.

Distance from the midline to the aneurysm as simple predictor of ischemic complication with small unruptured middle cerebral artery aneurysm surgery

BackgroundThis study aimed to clarify the risk factors for postoperative cerebral infarction in surgical clipping for prevalent small middle cerebral artery aneurysms (MCA Ans). MethodsThis retrospective study included 246 patients (mean age, 64.8 ± 10.0 years; 25.6 % males, 74.4 % females) with 258 aneurysms (mean aneurysm size, 5.4 ± 2.4 mm) who underwent direct surgery for unruptured MCA Ans at our institution from January 2015 to December 2020. All surgeries were performed under general anesthesia, incorporating indocyanine green videoangiography and transcranial motor-evoked potentials to enhance surgical precision and safety. The occurrence of surgery-related cerebral infarction was evaluated using postoperative CT scans within one week, comparing them with preoperative images. Patients were categorized based on the presence or absence of postoperative stroke and were analyzed for age, sex, past medical history, aneurysm size, number of clips used, and distance from the midline to the aneurysm. ResultsSeventeen patients had postoperative cerebral infarction (6.6 %, symptomatic 6, asymptomatic 11). There were no significant differences in terms of age, number of clips, or aneurysm size between the two groups; however, the distance from the midline to the aneurysm was significantly shorter in the stroke group (27.1 ± 4.7 mm; p < 0.001), with a cutoff value of 29 mm using the receiver operating characteristic curve. ConclusionSurgical clipping for MCA Ans presents a high risk of cerebral infarction for aneurysms located closer to the midline, emphasizing the importance of considering aneurysm location as a risk indication in surgical clipping.

Efficacy and safety of the contralateral approach to vascular lesions in the vertebral artery: patient series.

Endovascular treatment is preferred over microsurgical clipping for intracranial aneurysms in the posterior circulation. However, access to lesions, particularly those in the regions of the vertebral artery (VA) and the posterior inferior cerebellar artery (PICA), is technically challenging in terms of the vessel diameter of the ipsilateral VA or the branching angle of the PICA. Nine cases of intracranial aneurysms in the region of the PICA, which were endovascularly treated with an approach beyond the vertebrobasilar junction (VBJ) from the contralateral VA in the last 4 years, are described herein. All procedures, namely stent deployment, the use of a balloon catheter, and coiling, were safely performed using the contralateral approach. Neither rebleeding nor ischemic complications occurred. All patients had favorable outcomes and no recurrence. All aneurysms were successfully treated using an adjunctive technique with an additional approach beyond the VBJ from the contralateral VA. The combination of both ipsilateral and contralateral approaches to VA-PICA or PICA lesions contributes to safe and effective endovascular treatment. https://thejns.org/doi/10.3171/CASE24420.

053. Amyand’s Hernia Manifesting as Recurrent Incarcerated Lateral Inguinal Hernia: A Case Report

Background: Amyand’s hernia (AH) is a rare type of inguinal hernia, constituting approximately 1% of all inguinal hernia cases, where the appendix is found within the hernia sac. Typically, patients with AH are asymptomatic and the condition is often diagnosed during surgery. Due to its rarity and nonspecific presentation, diagnosis requires a high index of suspicion and relies heavily on imaging. Surgical intervention is the primary treatment. Here, we present a case of Amyand’s hernia managed surgically at our medium-complexity public hospital. Case: A 39-year-old man presented to the emergency room with an incarcerated right side inguinal hernia without any signs of ischemic complications. He was admitted, and an hernioplasty was performed, as an incidental finding we encountered an Amyand hernia treated without appendectomy and placement of a prosthetic mesh without any complications. During open hernia repair surgery, dense adhesions were found within the hernia sac. Upon releasing the adhesions, the appendix was discovered herniated into the inguinal canal, mildly congested but not inflamed. Consequently, a preperitoneal polypropylene mesh hernioplasty using the Lichtenstein tension-free repair technique was performed along with an appendectomy. The postoperative period was uneventful, and the patient was discharged on the second day. Conclusion: Amyand’s hernia is extremely rare, involving the appendix in the hernia sac, and accounts for 0.4–1% of all inguinal hernia cases. Literature indicates that the incidence of AH is very low, with only 0.1% of cases leading to acute appendicitis due to late presentation and missed diagnosis. Amyand’s hernia represents a small fraction of inguinal hernia cases and is usually diagnosed incidentally during surgery. This condition may remain asymptomatic, presenting similarly to a typical inguinal hernia. Management should be tailored based on the stage of appendiceal inflammation, presence of abdominal sepsis, and patient comorbidities. This individualized approach enables surgeons to effectively handle various presentations of Amyand’s hernia. Laparoscopy can serve both diagnostic and therapeutic roles in managing AH.

Successful management of mycotic anastomotic pseudoaneurysm of interposition vein graft following a carotid endarterectomy: a case report

BackgroundAnastomotic pseudoaneurysms of interposition vein grafts are a rare entity that requires urgent management to prevent life-threatening complications, such as rupture and thromboembolism, especially when involving the carotid arteries. As these are rare complications and literature is sparse, we believe that this case report can aid the decision-making process in similar circumstances.Case presentationA 49-year-old Ukrainian male patient presented with a false aneurysm of both distal and proximal anastomosis of an interposition vein graft between the common carotid artery and the internal carotid artery, which was previously performed as a bailout procedure after the patient developed a complication of carotid surgery. The patient was successfully treated with extra-anatomical interposition of a vein graft from the subclavian artery to the remnant of extracranial internal carotid artery and en bloc excision of the previous vein graft with the false aneurysms.ConclusionMycotic anastomotic pseudoaneurysms following carotid endarterectomy represent a rare yet serious complication in vascular surgery that requires urgent treatment. While endovascular techniques could represent an alternative option, open surgical repair is still the standard of care for this pathology, offering advantages in preventing postoperative ischemic complications and ensuring optimal long-term outcomes. The open approach provides direct visualization of the pseudoaneurysm. It allows the meticulous debridement of the infected tissues and an accurate reconstruction of the arterial wall with autologous or synthetic grafts. In light of the substantial evidence supporting its superiority, open surgical repair should remain the preferred approach in addressing mycotic anastomotic pseudoaneurysms following carotid endarterectomy. Future research should continue to explore advancements in other surgical techniques and refine treatment strategies to enhance patient outcomes in this challenging clinical scenario.

Respective impact of bleeding and ischemic complications of mortality after percutaneous coronary interventions: substudy from the FRANCE-PCI registry

Abstract Background Patients undergoing percutaneous coronary interventions (PCI) remain at high risk of both bleeding and ischemic events, both burdened with high morbimortality. The respective impact of both type of complications in contemporary PCI, however, remains unclear. Purpose To evaluate and compare the respective impact of ischemic and bleeding complications on mortality after PCI Methods The FRANCE PCI is an ongoing registry of consecutive French patients undergoing PCI and monitored for one year thereafter. Patients presenting with complications after the index PCI were categorized as ischemic complications in case of stent thrombosis, myocardial infarction, stroke or unplanned revascularization, as hemorrhagic complications in case of bleeding BARC ≥3 or as ischemic and hemorrhagic when both types of events occurred in the same patients. The impact of ischemic and hemorrhagic complications on mortality was evaluated separately for the index hospitalization and the 12-months follow-up after hospital discharge, using multivariate logistic model and Cox proportional hazards model, respectively. The multivariate Cox model was developed using complications as time-dependent variables and estimating the hazard ratios (HRs) over 3 periods of time (0 to 8 weeks, 8 to 24 weeks, and 24 to 52 weeks). Consequently, the proportional hazard assumption, tested using the Schoenfeld test, was met for each period. Multiple imputations were performed for missing data on covariates. Results A total of 54,599 patients, with a median age of 69 [60.0-78.0] years, 75.0% male, underwent PCI in 30 centers between 2014 and 2020, in an elective setting for 47% of the cases. During the index hospitalization, an ischemic and hemorrhagic complications occurred in 610 (1.1% 95%CI 1.0-1.2) and 531 (1.0% 95%CI 0.9-1.1) patients, respectively, while the mortality rate was 2.1% 95%CI 2.0-2.2. The association between ischemic, hemorrhagic and ischemic and hemorrhagic events with mortality was aOR 8.4 95%CI 6.4-10.9, aOR 10.3 95%CI 8.1-13.2 and aOR 13.2 95%CI 7.0-24.7, respectively. Among the 51,738 patients alive and not lost-to-follow-up after discharge, an ischemic and hemorrhagic complications occurred in 2,727 (5.3% 95%CI 5.1-5.5) and 1,022 (2.0% 95%CI 1.9-2.1) patients, respectively, while the mortality incidence was 3.8% 95%CI 3.6-4.0. The associations between ischemic, hemorrhagic and ischemic and hemorrhagic events with mortality according to the periods of time are detailed in Table 1 and Figure 1. Conclusion Both ischemic and hemorrhagic complications after PCI are associated with increased risk of mortality. The risk is particularly increased during the early period after the index PCI and diminishes over time, albeit faster after ischemic complications alone, compared to hemorrhagic events alone or the association of ischemic and hemorrhagic complications.

Effectiveness of an Impella versus intra-aortic balloon pump in patients who received extracorporeal membrane oxygenation: a nationwide inpatient database study

Abstract Background/Introduction Previous studies have suggested that left ventricular (LV) unloading with an intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (Impella) in combination with extracorporeal membrane oxygenation (ECMO) is associated with lower mortality; however, it is unclear which is better. Purpose This study aimed to evaluate the effectiveness of LV unloading with an Impella versus IABP on in-hospital mortality and other clinical outcomes. Methods Using the Japanese Diagnosis Procedure Combination database from September 28, 2016, to March 31, 2022, we identified inpatients who received an Impella or IABP in combination with ECMO (ECPella or ECMO+IABP group, respectively). The primary outcome was in-hospital mortality and the secondary outcomes were the length of hospital stay, length of ECMO, total hospitalization cost, and complications including major bleeding, an ischemic stroke, vascular complications, and renal replacement therapy during hospitalization. Propensity score matching was performed to compare the outcomes between the groups. We performed sensitivity analyses excluding patients who received extracorporeal cardiopulmonary resuscitation. Results Of 14,525 eligible patients, 603 (4.2%) received ECPella and 13,922 (96%) received ECMO+IABP. After propensity score matching, there was no significant difference in in-hospital mortality between the two groups (58.9% versus 56.6%; risk difference, 2.3%; 95% confidence interval, -3.9% to 8.5%). A Kaplan–Meier analysis with the log-rank test showed no significant difference in the 60-day in-hospital mortality between the two groups (P value = 0.114) (Figure 1). The ECPella group had a longer hospital stay (mean 42.8 days versus 33.7 days; risk difference, 9.1 days; 95% confidence interval, 2.6 to 15.6 days), a higher total hospitalization cost (12,573,000 yen versus 6,857,000 yen; risk differences, 5,716,000 yen; 95% confidence interval, 4,439,000 yen to 6,993,000 yen), and more frequent major bleeding (8.1% versus 5.8%; risk difference, 2.0%; 95% confidence interval, 0.007% to 4.0%), vascular complications (4.1% versus 2.2%; risk difference, 2.0%; 95% confidence interval, 0.04% to 3.9%), and renal replacement therapy during hospitalization (50.6% versus 41.1%; risk difference, 9.5%; 95% confidence interval, 3.0% to 15.9%) than the ECMO+IABP group (Figure 2). The results of the sensitivity analyses, excluding 6,360 patients (44%) who received extracorporeal cardiopulmonary resuscitation, showed similar results to those for the main analyses. Conclusions This nationwide inpatient database study showed that ECPella was not associated with a survival benefit but was associated with a longer hospital stay, a higher total hospitalization cost, and more complications than ECMO+IABP.Figure 1Figure 2

Shortened versus standard duration of dual antiplatelet treatment after percutaneous coronary intervention in patients with and without chronic kidney disease: a systematic review and meta-analysis

Abstract Background Impaired renal function is an established risk factor for recurrent cardiac events. The severity of chronic kidney disease (CKD) is related with an increased risk for both ischemic and bleeding complications. As a result, the clinical implications of antithrombotic therapies may be different in patients with CKD as compared to those without. Recently, shortened duration of DAPT, namely one to three months, after percutaneous coronary intervention (PCI) has been proven as a safe and feasible strategy in various different clinical scenarios, like in high-bleeding risk patients, in acute coronary syndromes and complex PCI. However, it remains debatable whether DAPT should be shortened in patients with high ischemic and bleeding risk, such as those with CKD. Purpose The aim of our systematic review and meta-analysis is to explore the safety and efficacy of shortened therapy (1-3 months; S–DAPT) in patients without and without CKD undergoing PCI. Methods Three major databases (MEDLINE, Cochrane Central Register of Controlled Trials, and Scopus) were screened for eligible randomized – controlled trials, or subgroup or post – hoc analyses of them. The studies should compare shortened (S–DAPT) with longer (&amp;gt;3 months) DAPT (L–DAPT) in patients undergoing PCI, and include data on CKD presence. The endpoints were Net Adverse Clinical Events (NACE) and Major Adverse Cardiac Events (MACE) and should be evaluated at 12 months. NACE and MACE were used as per trial defined. The effect of different DAPT regimens was assessed by calculating the risk ratio (RR) with 95% confidence interval (CI) using random-effects model (Mantel-Haenzel). Results A total of eight studies and 56,660 patients were included in our analysis; a notable proportion of patients (9.7%, N=5,466) suffered from CKD. Our analysis showed an overall benefit of S-DAPT in NACE (RR: 0.88, 95%CI: 0.81 – 0.95), which was consistent in patients with and without CKD (p-interaction=0.58). (Figure 1) No significant difference regarding MACE was observed between S-DAPT and L-DAPT (RR: 0.98, 95%CI: 0.90 – 1.06) in both patients with and without CKD (p-interaction=0.19). (Figure 2) Conclusions Our analysis showed an overall benefit of S-DAPT in NACE without any difference in MACE, with similar findings among patients with and without CKD. Thus, DAPT shortening could be a feasible and safe approach when it is required, even in patients with impaired renal function. Further randomized controlled trials focusing on patients with CKD are required for validating the previous results and exploring further benefits of abbreviated duration of DAPT.Net adverse clinical eventsMajor adverse cardiac events

Predictors of acute ischemic strokes and subsequent mortality in patients hospitalized for percutaneous coronary interventions

Abstract Background Acute ischemic strokes (AIS) occurring post percutaneous coronary intervention (PCI) are an infrequent but severe complication, resulting in increased mortality rates and morbidity in survivors. Purpose We aimed to investigate independent predictors of AIS and subsequent mortality in patients hospitalized for PCI in a nationwide cohort. Methods A retrospective analysis using on ICD-10-GM and OPS-codes obtained from 2006-2021 from the German Federal Statistical Office was performed. Patients with a peri-interventional AIS aged ≥18 years which were admitted for PCI were included in this analysis. A stepwise regression analysis was employed to identify factors independently associated with AIS and to determine variables linked to in-hospital mortality. Results From 4,910,430 PCI cases registered from 2006-2021, AIS occurred in 4,098 (0.08%) patients. Patients with an AIS were 70.9±11.3 years of age, predominantly male (65.3%) and displayed a high burden of comorbidities such as diabetes (36.1%), a prior medical history of atrial fibrillation (34.6%) and chronic kidney disease (19.4%). In patients with AIS, 27.4% presented with a ST-elevation myocardial infarction (STEMI), whilst 38.9% were admitted with a Non-STEMI. Concerning procedural characteristics, 84.2% underwent a coronary stent implantation, and in 5.5% cases a coronary thrombectomy was carried out. Important predictors of peri-interventional AIS after a PCI were: carotid artery disease, history of stroke, presentation with myocardial infraction, atrial fibrillation, and coronary thrombectomy. For variables like hyperlipoproteinemia, obesity and stent implantation an inverse association was noted (also see Figure 1A). With regard to mortality, during a mean in-hospital stay of 18 ± 15.1 days, a total of 18.1% (n=742) patients died. We identified several independent predictors of mortality including clinical presentation with cardiogenic shock, dialysis and STEMI as indication for PCI. A negative correlation with in-hospital mortality was seen for variables such as arterial hypertension and coronary stent implantation (see Figure 1B for full set of independently associated variables). Conclusion In a nationwide cohort of patients hospitalized for PCI over 16 years, we identified important predictors of AIS including carotid artery disease and coronary thrombectomy. Moreover, a substantial rate of in-hospital mortality as well as several predictors of death were recognized. Our findings might help clinicians identify patients undergoing PCI who are at highest risk for ischemic cerebral complications and subsequent mortality.

Predictors of periprocedural myocardial infarction following percutaneous coronary intervenction in NSTEMI

Abstract Background Percutaneous coronary intervention (PCI) has demonstrated a significant positive prognostic impact on outcomes in patients with Non-ST-elevation myocardial infarction (NSTEMI). However, PCI is associated with an increased risk of periprocedural complications, among which periprocedural myocardial infarction (PMI). Although risk factors of periprocedural events are only well established in patients undergoing PCI for chronic coronary syndrome with normal baseline cardiac troponin (cTn) levels, evidence on predictors of additional post-PCI myocardial infarction in patients with acute coronary syndrome who present elevated cTn levels at baseline (pre-PCI) is missing. Purpose To identify the predictors of PMI in patients affected by NSTEMI undergoing PCI. Methods We prospectively evaluated all NSTEMI patients admitted to our coronary care unit from 2017 to 2022 who underwent PCI. NSTEMI patients were managed according to the current European guidelines criteria. The diagnosis of PMI (type 4a myocardial infarction) was based on the Fourth Universal Definition of Myocardial Infarction. We only enrolled patients with stable (≤ 20% variation) or falling pre-procedure baseline cTn values. A multivariable logistic regression analysis was performed to investigate the factors independently associated with the occurrence of PMI after PCI. For the analysis, we selected the main known predictors of PMI after elective PCI, specifically age, serum creatinine, GRACE score &amp;gt; 140, multivessel disease, coronary bifurcation PCI, left main or proximal left anterior descending PCI, multivessel PCI and stent length ≥ 60 mm. Results The final court of the study included 1412 patients. PMI was recognized in 240 patients (17.0%). Although the patients who developed PMI had a higher risk profile as documented by a higher mean age, a higher complexity of atherosclerotic disease, and thus a significant technical difficulty of PCI compared to other patients, according to the multivariable model, only age [OR: 1.02 (95% CI: 1.01-1.04); p=0.006], coronary bifurcation PCI [OR: 3.71 (95% CI: 2.70-5.10); p&amp;lt;0.001], and stent length ≥ 60 mm [OR: 1.87 (95% CI: 1.30-2.68); p=0.001] were independent predictors of PMI. Interestingly, despite previous studies have demonstrated a predictive role of procedural complexity features, this was not completely confirmed by our analysis, in which left main or proximal left anterior descending PCI [OR: 0.92 (95% CI: 0.66-1.26); p=0.596] and multivessel PCI [OR: 0.83 (95% CI: 0.56-1.23); p=0.357] were not associated with an increased risk of periprocedural ischemic complications. Conclusions Among NSTEMI patients undergoing PCI, age, coronary bifurcation PCI and stent length ≥ 60 mm represent independent predictive factors of type 4a MI. This finding may have important clinical implications for clinical practice, providing valuable insights for the identification of higher-risk patients that can benefit from a more aggressive treatment.

Understanding perioperative risk determinants in carotid endarterectomy: the impact of compromised circle of Willis morphology on inter-hemispheric blood flow indices based on intraoperative internal carotid artery stump pulse pressure and backflow patterns.

Carotid artery stenosis (CAS) often requires surgical intervention through carotid endarterectomy (CEA) to prevent stroke. Accurate cerebrovascular risk assessments are crucial in CEA, as poor collateral circulation can lead to insufficient interhemispheric blood flow compensation, resulting in ischemic complications. Therefore, understanding perioperative risk determinants is vital. This study aims to determine the impact of compromised circle of Willis (CoW) morphology on inter-hemispheric blood flow, focusing on indices based on intraoperative internal carotid artery stump pulse pressure and backflow patterns. In 80 CAS patients who underwent CEA, preoperative CT angiography for CoW was conducted. Patients were categorized into five subgroups based on their CoW anatomy and three additional groups based on intraoperative internal carotid artery (ICA) stump backflow patterns evaluated by the surgeon. Continuous blood pressure signals, including systolic, diastolic, mean, and pulse pressure values, were recorded during the procedure. The relationship between CoW anatomical variants and the systolic and diastolic segments of the averaged pressure waveforms, particularly diastolic pressure decay, was analyzed. The correlation between CoW anatomy and stump backflow intensity was also examined. Significant variability in ICA stump backflow and pressure values was evident across CoW variants. Patients with compromised CoW morphology exhibited weaker backflow patterns and lower ICA stump pulse pressure values, consistent with impaired interhemispheric blood flow. Notably, ICA stump diastolic pressure decay was consistent across most CoW variant groups, indicating developed collateral circulation in cases with CoW anomalies. Thus, impaired CoW integrity is associated with compromised interhemispheric blood flow indices based on intraoperative ICA stump pulse pressure and backflow patterns during CEA. Integrating intraoperative pulse waveform analysis with preoperative CT angiography provides a more detailed assessment of cerebrovascular risk, guiding the selective use of shunts. This combined approach may improve surgical outcomes and patient safety by identifying patients at increased risk of perioperative neurological events due to CoW anomalies.

Percutaneous decannulation of extracorporeal membrane oxygenation using MANTA device: A real-world single-center experience.

The MANTA vascular closure device (VCD) represents a novel approach to achieving hemostasis after large-bore femoral access procedures. Numerous clinical studies have evaluated the efficacy of the MANTA device across a range of patient populations undergoing different procedures. However, there is still a paucity of data available concerning the use of MANTA devices in aiding the decannulation of venoarterial extracorporeal membrane oxygenation (VA-ECMO). To present our single-center experience of utilizing the MANTA VCD in patients undergoing this procedure. This single-center study included all patients undergoing percutaneous decannulation of femoral VA-ECMO using the MANTA plug-based VCD between January 2021 and October 2023 at University Hospitals Cleveland Medical Center. Inclusion criteria were adult patients who required prolonged (> 24 hours) hemodynamic support with VA-ECMO. Outcomes included all-cause mortality, hemostasis, bleeding, limb ischemia, and site infection. This is a retrospective cohort study of 19 patients with a mean age of 56.8 years. Twelve of them were males with a mean body mass index of 29. The most common extracorporeal membrane oxygenation indication was acute coronary syndrome complicated by cardiogenic shock at 36.8%. The mean length of intensive care unit stay for these patients was 18.8 ± 8.42 days. Seventeen out of 19 patients survived to discharge. The MANTA device was successfully deployed in 19 patients, with 10 procedures conducted at the bedside and 9 in an operating room setting. Complete hemostasis was achieved within 5 minutes of MANTA deployment in 17 out of 19 patients. In 2 patients manual compression after Manta deployment was required to achieve adequate hemostasis. Additionally, acute lower extremity ischemia was noted in two patients, necessitating endovascular interventions. No infections were reported at the site of MANTA deployment. Overall, based on our experience and that of other centers, the MANTA VCD has proven to be a simple, safe, and effective percutaneous technique for facilitating in the OR, but most of all it opens the opportunity for bedside VA-ECMO decannulation. Post-decannulation ischemic complications are higher in this series of sick patients when compared with elective procedures like transcatheter aortic valve replacement and endovascular aneurysm repair. Additionally, operators should be mindful of the incidence of ischemic complications. Distal Doppler pulse signals should always be checked, to indicate bailout options when this occurs.

Pooled comparative analysis of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with left ventricular assist device.

A thorough literature search was conducted on patients with Left Ventricular Assist Device (LVAD) and aortic insufficiency undergoing transcatheter aortic valve replacement (TAVR). We identified all original research studies that compared the long-term outcomes of surgical transcatheter aortic valve replacement (SAVR) versus TAVR for patients with LVAD, published between 1990 and 2023. The primary endpoint was the composite of in-hospital mortality, stroke, transient ischemic attack, myocardial infarction (MI), pacemaker implantation, vascular complications and cardiac tamponade. Secondary endpoints were the median overall survival (OS), the incidence of acute kidney injury (AKI), any bleeding needing transfusions or reintervention and cost. A total of fourteen studies and 358 patients were included (TAVR: 242; SAVR: 116). The composite outcome, the incidence of AKI, the bleeding needing transfusion, along with cost were significantly higher in the SAVR group. In addition, there was no significant difference between TAVR and SAVR in terms of median OS. The median OS in the TAVR group was 18 months. Finally, the most common causes of death were progression of heart failure and pneumonia. The present meta-analysis indicates that TAVR is associated with enhanced outcomes compared to SAVR for patients with LVAD presenting aortic insufficiency. Further well-designed original studies with greater sample sizes are necessary to validate our findings.

Predictive value of the systemic immune-inflammation index for periprocedural complications in flow diverter treatment for patients with intracranial aneurysms.

Flow-diverter devices (FDs) are effective in treating intracranial aneurysms (IAs) but carry substantial periprocedural risks, particularly ischemic complications. This study aimed to determine if elevated Systemic Immune-Inflammation Index (SII) can independently predict these risks and assess the impact of age and dual antiplatelet therapy on this association. We conducted a retrospective analysis of patients treated with FDs between February 2016 and August 2023, using blood samples taken within six days before surgery to calculate SII. Logistic regression and decision tree analyses assessed the link between SII and periprocedural complications, with subgroups exploring influencing factors. Multivariable analysis identified high SII as an independent predictor of periprocedural complications (OR = 5.306, 95% CI: 1.367-18.455; P = 0.009). The decision tree model confirmed SII > 0.437 as a critical threshold. Subgroup analysis showed a pronounced association of SII with periprocedural complications in patients ≥ 65 years (OR = 36.979, 95% CI: 2.103-650.134; P = 0.014) and in those on clopidogrel plus aspirin therapy (OR = 16.921, 95% CI: 2.733-104.746; P = 0.002). An elevated Systemic Immune-Inflammation Index (SII) > 0.437 significantly correlates with increased periprocedural complications (6.5% vs. 1.8%, P = 0.017). Although not statistically significant, higher SII is associated with a greater rate of ischemic events (3.9% vs. 0.9%). Elevated preoperative SII independently predicts periprocedural complications, particularly ischemic events, in patients undergoing FDs treatment for intracranial aneurysms. This association is particularly pronounced in older patients (> 65 years) and those receiving dual therapy with clopidogrel plus aspirin. Trial Registration: ClinicalTrials.gov (NCT06446778). Registered on May 22, 2024.

Posterior short ciliary arteries ischemia following embolization of anterior ethmoid artery to treat dural arteriovenous fistulas: a case report

BackgroundThe Onyx™ Liquid Embolic System is a non-adhesive liquid embolic agent, which has been proved by the US FDA for embolization of lesions in the peripheral and neurovasculature since 2005. We reported a case of ischemic optic neuropathy after using Onyx-18 to embolize the anterior ethmoid arteries that feeding dural arteriovenous fistulas (DAVF).Case presentationA 57-year-old Asian male presented with anterior cranial fossa DAVF underwent embolotherapy by delivering Onyx-18 through a microcatheter into the anterior ethmoid arteries under angiography guidance. The interventional procedure was successful and no clear evidence was found pointing to untargeted occlusive embolus. But after the surgery the patient experienced delayed painless vision loss in the right eye (RE). The fundoscopy showed unilateral papilledema with pale optic disc in RE, accompanied by significant edema and thickening in the retinal nerve fiber layer (RNFL) of macula. The fundus fluorescence angiography showed that most of the optic disc in RE had postponed or absent fluorescence filling. Visual evoked potential (VEP) confirmed that the amplitude of the P100 component was decreased in RE without significant prolongation of the latency. The patient was diagnosed with anterior ischemic optic neuropathy, but immediate pulse steroid therapy failed to rescue his vision.ConclusionPreoperative evaluation of the patient’s hemodynamic status and fundus examination are essential for assessing the risk of ischemic ocular complications, and the non-adhesive liquid embolic agent Onyx-18 should be used cautiously during endovascular embolization of intracranial artery.

Essential thrombocythemia complicated by multivessel intracranial dolichoectasia with subarachnoid hemorrhage and recurrent cerebral infarction

BackgroundPatients with essential thrombocythemia (ET) can develop systemic thrombotic and hemorrhagic vascular complications due to increased and dysfunctional platelets.Case presentationWe encountered a 49-year-old Japanese woman with a history of essential ET, cerebral infarction, hypertension, and hyperlipidemia. She had been taking anagrelide (2.5 mg/day) and aspirin (100 mg/day) and had vomited at home. At the time of admission to our hospital, she was in a deep stupor. We thought these symptoms were caused by intracranial hypertension. Head computed tomography showed severe subarachnoid hemorrhage (SAH) at the interhemispheric fissure, hematoma at the corpus callosum, and intraventricular hemorrhages. Digital subtraction angiography demonstrated multiple dilated, stenotic, tortuous intracranial arteries, and a dissecting aneurysm at the right anterior cerebral artery (ACA). The dissecting aneurysm measured 7.7 × 15.5 mm, and a bleb was observed. Our diagnosis was ruptured ACA dissecting aneurysm and diffuse intracranial arterial dolichoectasia (DIADE). We performed stent-assisted coil embolization of the aneurysm. She remained apathetic and manifested unilateral apraxia and alien limb syndrome due to a partial callosal disconnection. Two months thereafter her symptoms gradually improved, her consciousness level and limb function improved, and her modified Rankin scale (mRS) score was 2. However, when we tapered her antiplatelet therapy, she again developed an acute cerebral infarct.ConclusionsThis is the first presentation of a patient with ET complicated by DIADE, both of which can result in ischemic and hemorrhagic vascular complications including SAH. As antithrombotic therapy in patients with DIADE and ET may be associated with higher hemorrhage rates, its effects must be monitored carefully.