Neurointerventional Procedures Research Articles

Cangrelor for neurointerventional procedures: A systematic review.

Thromboembolism is a complication of neurointerventional procedures that requires patients to be placed under antiplatelet therapy. Current options for antiplatelet therapies have a delayed onset of action that prevents a rapid door to puncture transition for patents presenting in acute settings. Cangrelor (Kengreal, Chiesi, USA) is an intravenous P2Y12 platelet inhibitor approved in percutaneous coronary interventions that has an immediate onset of action and half-life between 2 and 6 min. Thus, the goal of this study is to report on the safety, effectiveness, and indications for using Cangrelor in neurointerventional procedures. A systematic review of studies describing the use of Cangrelor in neurointervention was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search was conducted on PubMed, Ovid Medline, and Embase databases through June 2023. Seventeen studies with 314 patients met inclusion criteria. The most common indication for Cangrelor use was acute ischemic strokes: 70% followed by aneurysms 27.4%. The Infusion protocol varied from 5 to 30 μg/kg bolus and 1 to 4 µg/kg/min infusion with 30 μg/kg bolus and 4 µg/kg/min infusion being reported in 64.7% of studies. Intra-operative platelet reacting unit levels were below 200 in all the studies that reported it, and the percentage of hemorrhagic, thromboembolic, and deaths occurrence in this patient cohort was respectively 11.1%, 4.8%, and 8.6%. Cangrelor appears to be a promising P2Y12 platelet inhibitor for neurointerventional procedures. However, large, randomized trials are needed to determine the full range of its effects in neurointerventional procedures.

320 Intraoperative Angiography in Neurosurgery: Temporal Trend, Access Site, and Operative Indication Considerations From a Six-year Institutional Experience

INTRODUCTION: Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiogram (IOA). However, in line with trends in cardiac interventional vascular access preferences, transradial approach (TRA) and transulnar approach (TUA) are gaining popularity due to favorable safety and patient satisfaction outcomes. METHODS: Between July 2016 and December 2022, 317 angiograms were included based on our case definition, comprising 59 TRA cases, 11 TUA cases, 243 TFA, and four transpopliteal cases. Fluoroscopy time, contrast dose, reference air kerma (RAK), and dose area products (DAP) per target vessel catheterized were the primary endpoints of interest. Univariate and multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure metrics. RESULTS: Contrast dose per vessel catheterized was significantly lower in TRA/TUA cases versus TFA cases (p = 0.001), but radiation exposure metrics did not differ between access site groups. TRA/TUA versus TFA does not significantly predict elevated levels of radiation exposure or contrast dose. Aneurysm cases were associated with significantly lower odds of elevated radiation exposure for all radiation metrics (p < 0.05) whereas AVM cases had higher odds of elevated radiation exposure across all measures (p < 0.01). There was a significant relationship between case number and operative indication over the study period (p < 0.001) with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of AVF and AVM. CONCLUSIONS: TRA and TUA are safe and effective access site options for neurointerventional procedures and are increasingly employed. Cases using wrist access may be associated with a lower contrast dosing for patients.

Anatomical evaluation of P1 segment of posterior cerebral artery and posterior communicanting artery in 340 human hemispheres: a proposal for morphological classification.

The aim of our study is to examine the morphometry of the P1 segment of the posterior cerebral artery (P1) and the posterior communicating artery (PcomA) and to present a descriptive classification according to morphometric findings. 340 hemispheres from 170 cadavers were included. The outer diameters of P1 and PcomA were measured with ImageJ software. Then, the configurations of the posterior cerebral artery were revealed as fetal, adult and transitional. The findings were correlated with the demographic information of the cadavers such as gender, body mass index (BMI), age. According to the morphometric findings, 83.75%, 13.85% and 2.40% of the posterior cerebral arteries were found to be adult, fetal and transitional, respectively. The fetal type was more common in cadavers aged 60years and older (13.73%) compared to the 18-39 and 40-59 age groups. In addition, P1 and PcomA diameters also increased with age. Fetal and transtional types showed a similar low distribution in people with low (< 18.5), normal (18.5-24.9), overweight (25-29.9) and obese (> 30) BMI, whereas adult type was found in cadavers with a normal BMI of 140/303. We believe that the findings of our study will contribute to the planning of neurointerventional procedures, the development of endovascular devices, the success of invasive procedures and the reduction of complications.

Abstract TP105: Neurointervention Simulation Workshop for Neurology Residents

Background: Endovascular Thrombectomy is now standard of care and widely used treatment for large vessel occlusion strokes in appropriately selected patients. Neurology Residents have minimal exposure to formal neuro-interventional procedures which may lead to limited technical understanding and comfort in discussing the procedure with patient and interdisciplinary teams. Methods: A prospective quasi-experimental, pretest/posttest study was conducted. Participants included 18 Neurology Residents in a standardized simulation of endovascular thrombectomy procedure using a flow model supervised a neuro-interventionalist followed by a debriefing session. Questionnaire included items on technical knowledge of endovascular thrombectomy as well as assessment of subjective comfort related to procedure and consent process. Responses were analyzed using Pearson coefficient. Results: On a 10-point Likert scale, median score for trainee comfort in discussing endovascular thrombectomy with patient/family and stroke attending increased from 5 to 8 (p &lt; 0.05) and 4 to 7 (p &lt; 0.05) respectively. Residents also reported improvement in procedural understanding with median score of 7 following simulation compared to 2 prior (p &lt; 0.05). Conclusion: Observable enhancements in procedural comprehension, accompanied by increased subjective comfort in engaging in discussions concerning the endovascular thrombectomy procedure with patients and/or their family members, were clearly identified among Neurology Residents following their engagement in simulation-based training. The utilization of neuro-interventional simulation presents a promising avenue for complementing the skill development of trainees involved in the management of patients with acute large vessel occlusion, who are being evaluated for potential mechanical thrombectomy interventions.

Radiation dose to multidisciplinary staff members during complex interventional procedures

IntroductionComplex interventional radiology procedures involve extensive fluoroscopy and image acquisition while staff are in-room. Monitoring occupational radiation dose is crucial in optimization. The purpose was to determine radiation doses received by staff involved in complex interventional procedures performed in a dedicated vascular or neuro intervention room. MethodsIndividual real-time radiation dose for all staff involved in vascular and neuro-interventional procedures in adult patients was recorded over a one-year period using wireless electronic dosimeters attached to the apron thyroid shield. A reference dosimeter was attached to the C-arm near the tube housing to measure scattered, unshielded radiation. Radiology staff carried shoulder thermo-luminescent dosimeters with monthly read-out to monitor dose over time. ResultsOccupational radiation dose was measured in 99 interventional procedures. In many cases prostate artery embolization procedures exposed radiologists to high radiation doses with a median of 15.0 μSv and a very large spread, i.e. 0.2–152.5 μSv. In all procedures except uterine fibroid embolization radiographers were exposed to lower doses than those of radiologists, with endovascular aortic repair being the procedure with highest median exposure to assisting radiographers, i.e. 2.2 μSv ranging from 0.1 to 36.1 μSv. Median radiation dose for the reference dosimeter was 670 μGy while median staff dose for all procedures combined was 3.2 μGy. ConclusionRadiation doses for multiple staff were determined and the ratio between staff dose and reference dosimeter indicated proper use of shielding in general. Some high-dose procedures may need further optimization for certain staff members, especially those not primarily employed in radiology. Implications for practiceThe study provides benchmark doses that may be used widely in audits and in the ongoing effort to optimize radiation protection for staff in interventional radiology.

Periprocedural management of patients presenting for neurointerventional procedures using flow diverters for complex intracranial aneurysms: An anesthetist's perspective - A narrative review.

Complex intracranial aneurysms pose significant challenges in the realm of neurointervention, necessitating meticulous planning and execution. This article highlights the crucial roles played by anesthetists in these procedures, including patient assessment, anesthesia planning, and continuous monitoring and maintaining hemodynamic stability, which are pivotal in optimizing patient safety. Understanding these complex procedures and their complications will aid the anesthetist in delivering optimal care and in foreseeing and managing the potential associated complications. The anesthetist's responsibility extends beyond the procedure itself to postprocedure care, ensuring a smooth transition to the recovery phase. Successful periprocedural anesthetic management in flow diverter interventions for complex intracranial aneurysms hinges on carefully orchestrating these elements. Moreover, effective communication and collaboration with the interventional neuroradiologist and the procedural team are emphasized, as they contribute significantly to procedural success. This article underscores the essential requirement for a multidisciplinary team approach when managing patients undergoing neurointerventions. In this collaborative framework, the expertise of the anesthetist harmoniously complements the skills and knowledge of other team members, contributing to the overall success and safety of these procedures. By providing a high level of care throughout the periprocedural period, anesthetists play a pivotal role in enhancing patient outcomes and minimizing the risks associated with these intricate procedures. In conclusion, the periprocedural anesthetic management of neurointervention using flow diverters for complex intracranial aneurysms is a multifaceted process that requires expertise, communication, and collaboration.

Early Experience With the Dual-Mode Radial-Access Catheter Armadillo in Neuroendovascular Procedures via the Radial Approach: A Multicenter Study of 71 Patients

BACKGROUND AND OBJECTIVES: The transradial approach is increasingly being adopted by neurointerventionalists after several studies showed its safety, efficacy, and patient satisfaction. However, the use of non–radial-specific devices for transradial procedures is a major barrier for transradial adoption. In this study, we aim to demonstrate the efficacy, technical feasibility, and safety of the Armadillo dual-mode guide catheter (Q'Apel Medical Inc.) as a radial-specific catheter in various neurovascular pathologies. METHODS: This is a multicenter retrospective study of 71 patients who underwent neurointerventional procedures via the transradial route using the Armadillo guide catheter between 2021 and 2023. RESULTS: Our study cohort comprised 71 patients, mostly females (n = 33, 63.5%) with a mean age of 59.1 ± 13.5 years. 13 (18.3%) patients underwent carotid artery stenting and angioplasty, 39 (54.9%) aneurysm treatment, 9 (12.7%) vascular malformation embolization, 5 (7.0%) tumor embolization, and 5 (7.0%) middle meningeal artery embolization for chronic subdural hematomas. The mean procedure time was 61.4 ± 33.5 min, mean fluoro time was 29.6 ± 14.4 min, and mean radiation exposure was 93.3 ± 56.3 Gy cm2. During the procedures, 70 (98.6%) target vessels were successfully catheterized. The rate of access site complications was 0%, and 1 (1.4%) patient required conversion to the transfemoral route. CONCLUSION: The use of the Armadillo catheter showed promising outcomes in terms of safety, effectiveness, and technical feasibility in various neuroendovascular procedures, demonstrating a high success rate and low morbidity rate.

Navigating the crossroads: Insights into cardiology’s influence on neurointerventional procedures

&lt;p&gt;Since Egaz Moniz introduced angiography, neurovascular interventions have undergone significant advancements. The integration of advanced biomaterials has refined endovascular devices and techniques for complex vascular lesions. The domain of neurointerventions includes neuroendovascular surgery, endovascular neurosurgery, and interventional neurology. Notably, in regions with limited neurointerventional specialists, interventional cardiologists are increasingly treating cerebrovascular strokes. The congruence between coronary and carotid interventions has facilitated the development of adaptable cerebrovascular tools, many inspired by those in cardiac catheter labs. This article provides an overview of key developments in neurointerventions, with a focus on the adaptation of tools between coronary and cerebrovascular procedures.&lt;/p&gt;

Functional Cerebral Venous Anatomy: A Perspective on Venous Collaterals Part II, Infratentorial Venous System

Abstract The infratentorial veins are densely packed in a smaller space compared to the supratentorial veins and have many variations, such as disconnections and anastomoses. Knowledge of the functional venous anatomy of the posterior fossa is becoming increasingly important in neurointerventional procedures. The basic brainstem veins are longitudinal and transverse veins. The venous drainage of the brainstem and cerebellum follows 3 paths: superior (Galenic), anterior (petrosal), and posterior (torcular). Knowledge of the basic venous anatomy of the brainstem and cerebellum is essential for understanding the routes and patterns of venous drainage under pathological conditions, particularly in arteriovenous shunts. This review describes posterior fossa venous development and the functional venous anatomy of the posterior fossa, mainly the veins of the brainstem, cerebellum, and the emissary veins.

Neurointerventions on two generations of angiography systems: Recent systems reduce radiation exposure by half

PurposeFluoroscopically-guided neurointervention may be associated with prolonged procedure time and substantial radiation exposure to the patient and staff. This study sought to examine technological features affecting the potential radiation exposure reduction of new angiography systems, compared to older systems, for neurointerventional procedures. MethodsConsecutive neurointerventional patients (2020–2022) were retrospectively analyzed. The air kerma at the reference point (Ka,r) and kerma-area product (KAP) were compared between Artis icono and Artis zee (Siemens) using statistical analyses (two-tailed t tests), where P < 0.05 is considered significant. X-ray tube potential and copper filtration were examined. Tests with an anthropomorphic phantom (Sun Nuclear) on Artis icono were conducted and entrance skin exposure and x-ray spectral half value layer were measured. Effective spectral filtration was characterized by x-ray spectral modeling. ResultsThe number of procedures was 1158 [median (range) age, 59 (7–95) years] on Artis zee and 1087 [60 (1–95) years] on Artis icono, without significant difference in age (p = 0.059) between cohorts. Ka,r was 925.4 (890.6–960.1) mGy [mean (95 % CI)] and KAP was 119.8 (115–124.5) Gy∙cm2 on Artis zee. The measures were 48–50 % lower on Artis icono, 440.5 (411.7–469.4) mGy (Ka,r) and 59.5 (55.4–63.6) Gy∙cm2 (KAP); while the difference in fluoroscopic time between the two generations of angiography systems was insignificant (p = 0.55). ConclusionsThe newer angiography system, with updated hardware and software, was found to result in half the radiation exposure compared to older technology of the same manufacturer, even though fluoroscopic time was similar.

Dual Antiplatelet Therapy Regimens and Duration for Intracranial Stenting Procedures: Literature Review

Objectives of the study. Our aim was to analyse different antithrombotic drug regimens and duration in intracranial stenting procedures (stent assisted coiling, flow diverter) for unruptured aneurysms and based on the literature review from 2017–2023 to implement dual antiplatelet therapy algorithm for neuro-interventional procedures in Lithuania. Research methods and methodology. A comprehensive literature search of PubMed, BioMed Central, BMJ Journals, EBSCO Publishing, SAGE Journals Online, ScienceDirect, SpringerLink was conducted by two independent readers (MP, GŠ) for studies published from January 2017 to April 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. 23 studies: 6 retrospective cohort, 11 retrospective case-control, 1 prospective cohort, 1 prospective randomized-control, 1 systemic literature review, 3 metanalysis observational studies were identified. Results and conclusions. We found widespread variation in practices even among the same country centres, lending credence to the importance of a future prospective studies of dual antiplatelet drug therapy (DAPT) regimens and duration for the purpose of deriving optimal methods and streamlining tactics. Our suggested algorithm for DAPT in neuro-interventional procedures in Lithuania is provided in Graph 1.

Distal versus conventional transradial access for diagnostic cerebral angiography and neurointerventional procedures: A systematic review and meta-analysis.

Distal transradial artery access (dTRA) has received increasing consideration for performing diagnostic cerebral angiography and neurointerventional procedures. In this meta-analysis, we aim to evaluate the safety and efficacy of dTRA compared to conventional transradial access (cTRA) for cerebral angiography and neurointerventions. A systematic review and meta-analysis were conducted on studies investigating outcomes of dTRA and cTRA in neurointerventions. The primary outcome was technical success rates. Secondary outcomes included access site complication rates, crossover rates to alternative vessels, fluoroscopy time, and contrast volume. The random effects model was used to calculate the mean difference (MD) and odds ratios (OR) with 95% confidence intervals (Cl). Eight retrospective observational studies with a total of 1477 patients who underwent 1175 diagnostic cerebral angiography and 516 neurointerventional procedures using 546 dTRA and 1164 cTRA approaches were included in our meta-analysis. The technical success rate was similar between dTRA and cTRA groups (95.8% vs 91.4%; OR:1.65; 95% Cl: 0.52 to 5.22; P = 0.40). Similarly, no difference was seen in dTRA and cTRA regarding access site complications (2% vs 1.4%; OR: 1.31; 95% CI: 0.47 to 3.61; P = 0.61) and access site crossover (2.1% vs 5.3%; OR: 0.55; 95% Cl: 0.28 to 1.05; P = 0.07). After resolving heterogeneity among included studies, dTRA was associated with a shorter fluoroscopy time (MD: -0.91 min; 95% CI: -1.74 to -0.09; P = 0.03) and lower contrast volume (MD: -8.32 mL; 95% CI = -14.7 to -1.94; P = 0.011). Our findings suggest that the dTRA approach is a safe and effective alternative to the cTRA approach in patients undergoing cerebral angiography and neurointerventions.

Arm-only combined transarterial and transvenous access for neurointerventional procedures: a double-center retrospective study.

This study aims to share our experience with the arm-only combined transarterial and transvenous access approach for neurointerventional procedures and evaluate its efficacy and safety. The arm-only combined transarterial and transvenous access approach was performed using the right/bilateral proximal radial arteries and the right forearm superficial vein system, guided by ultrasonic guidance. Arterial access closure was achieved using a transradial band radial compression device, while manual compression was utilized for venous approach closure. Thirteen procedures were successfully performed using the arm-only combined transarterial and transvenous access approach, yielding favorable outcomes. The procedures included dural arteriovenous fistula embolization (seven cases), cerebral arteriovenous malformation embolization (four cases), venous sinus thrombosis catheter-directed thrombolysis and intravenous thrombectomy (one case), and cerebral venous sinus stenosis manometry (one case). All procedures were uneventful, allowing patients to ambulate on the same day. At discharge, all patients exhibited modified Rankin scores of 0-2, without any access site or perioperative complications. This double-center study preliminarily demonstrates the feasibility and safety of arm-only combined transarterial and transvenous access applied in neurointerventional procedures for complicated cerebrovascular diseases. The proximal radial artery and forearm superficial vein are recommended as the primary access sites. Unobstructed compression is strongly recommended for radial approach closure. This study aimed to add evidence and experience on the arm-only combined transarterial and transvenous access, as a new approach, for neurointerventional treatment that required arteriovenous approaches.

In vivo study of the utility of selective intra-arterial injection of thiopental for neuroprotection in reversible cerebral ischemia.

Neuroprotective agents are needed to reduce cerebral damage during surgical or neurointerventional procedures including stroke patients. To evaluate if thiopental can be used as a neuroprotective agent when injected intra-arterially in a transient ischemia model. In total, 24 rabbits were studied as four groups of six animals. Group 1 served as the control group. In group 2, transient ischemia was obtained by intracarotid administration of degradable starch microspheres (DSM). Group 3 was administered thiopental intra-arterially via the carotid artery. Group 4 (experimental group) received both thiopental and DSM intra-arterially. DSM and thiopental were administered through a microcatheter placed into the common carotid artery via the central ear artery access. After sacrifice, apoptotic cells in the cerebral tissues of the animals were evaluated in H&E and TUNEL stained slides. There was a significant increase in the number of apoptotic glial or neuronal cells in group 2 compared to the control group and group 3. The mean number of both the apoptotic neuronal cells (6.8 ± 2.1 vs. 2.5 ± 1.3, P < 0.001) and the apoptotic glial cells (9.4 ± 3.1 vs. 4.6 ± 1.6, P < 0.001) were higher in group 2 compared to group 4. In addition, a higher level of neurological improvement was observed in group 4 compared to group 2 based on neurological assessment score. The intra-arterial administration of thiopental has a protective effect on both glial and neuronal cells during temporary cerebral ischemia in low doses.

Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience.

Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiography (IOA). However, in line with trends in cardiac interventional vascular access preferences, the transradial approach (TRA) and transulnar approach (TUA) have been gaining popularity owing to favorable safety and patient satisfaction outcomes. To compare the efficacy and safety of TRA/TUA and TFA for cerebral and spinal IOA at an institutional level over a 6-year period. Between July 2016 and December 2022, 317 angiograms were included in our analysis, comprising 60 TRA, 10 TUA, 243 TFA, and 4 transpopliteal approach cases. Fluoroscopy time, contrast dose, reference air kerma, and dose-area products per target vessel catheterized were primary endpoints. Multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure and to assess time trends in access site selection. Contrast dose and radiation exposure metrics per vessel catheterized were not significantly different between access site groups when controlling for patient position, operative region, 3D rotational angiography use, and different operators. Access site was not a significant independent predictor of elevated radiation exposure or contrast dose. There was a significant relationship between case number and operative indication over the study period (P<0.001), with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of arteriovenous malformation, AVF, and moyamoya disease. TRA and TUA are safe and effective access site options for neurointerventional procedures that are increasingly used for IOA.

The Aristotle 18 and 24 microwires in neuroIntervention: Early experience at a single centre.

Current neurointerventional procedures are expanding the use of large bore microcatheters, of up to 0.033" inner diameters, to accommodate intrasaccular flow disruptors or neck-bridging devices, including flow diverters. The use of large bore microwires may mitigate the ledge gap between wire and catheter, facilitate navigation and offer support in distal tortuous anatomy. We aim to report our early experience using the novel Aristotle (Scientia Vascular, West Valley City, UT) 18 and 24 microwires in neurovascular interventions. We analysed neurointerventional procedures in which the Aristotle 18 and 24 microwires were used at a single centre. Prospectively collected data, from March 2022 to February 2023, including patient's clinical outcome (successful target vessel, aneurysm catheterisation, peri-procedural complications (thromboembolic, haemorrhagic, vessel dissection or perforation) were analysed. Overall, the use of Aristotle 18 and 24 microwires was recorded in 84 neurointerventional procedures during the study period, including endovascular aneurysm treatment (n = 30), endovascular thrombectomy (n = 46), dural venous sinus manometry/stent placement (n = 7), and extracranial carotid artery stent placement (n = 1). The Aristotle 18 microwire was used in conjunction with 0.021" microcatheters and the Aristotle 24 microwire with the 0.027 or 0.033" microcatheters. In all cases (100%), the target vessel or aneurysm was reached with the microwire, allowing seamless advancement of the selected microcatheters. No procedure related complications were recorded. The use of the Aristotle 18 and 24 microwires in neurointerventional procedures is feasible and safe. The microwires provide reduced ledge gap, improved torquability, support and safety over standard 0.014" microwires.

Early exploration of the economic impact of transradial access (TRA) versus transfemoral access (TFA) for neurovascular procedures in Spain

IntroductionTransfemoral access (TFA) is the primary access approach for neurointerventional procedures. Transradial access (TRA) is established in cardiology due to its lower complications, yet, it is at its early stages in neuroprocedures. This study performs an early exploration of the economic impact associated with the introduction of TRA in diagnostic and therapeutic neuroprocedures from the Spanish NHS perspective.MethodsAn economic model was developed to estimate the cost and clinical implications of using TRA compared to TFA. Costs considered access-related, complications and recovery time costs obtained from local databases and experts’ inputs. Clinical inputs were sourced from the literature. A panel of eight experts from different Spanish hospitals, validated or adjusted the values based on local experience. Hypothetical cohorts of 10,000 and 1000 patients were considered for diagnostic and therapeutic neuroprocedures respectively. Deterministic sensitivity analysis was performed.ResultsTRA in diagnostic procedures was associated with lower costs with savings ranging between €486 and €157 depending on the TFA recovery time considered. TRA is estimated to lead to 158 fewer access-site complications. In therapeutic procedures, TRA resulted in 76.4 fewer complications and was estimated to be cost-neutral with an incremental cost of €21.56 per patient despite recovery times were not included for this group. Variation of the parameters in the sensitivity analysis did not change the direction of the results.LimitationsClinical data was obtained from literature validated by experts therefore results generalizability is limited. In therapeutic neuroprocedures, there is an experience imbalance between approaches and recovery times were not included hence the total impact is not fully captured.ConclusionsThe early economic model suggests that implementing TRA is associated with reduced costs and complications in diagnostic procedures. In therapeutic procedures, TRA lead to fewer complications and it is estimated to be cost-neutral, however its full potential still needs to be quantified.

Femoral access site complications following neurointerventional procedures: economic implications at a single center.

Transfemoral access (TFA) has been the traditional route of arterial access for neurointerventional procedures. Femoral access site complications may occur in 2%-6% of patients. Management of these complications often requires additional diagnostic tests or interventions, each of which may increase the cost of care. The economic impact of a femoral access site complication has not yet been described. The objective of this study was to evaluate the economic consequences of femoral access site complications. The authors conducted a retrospective review of patients undergoing neuroendovascular procedures at their institute and identified those who experienced femoral access site complications. The subset of patients experiencing these complications during elective procedures was matched in a 1:2 fashion to a control group undergoing similar procedures and not experiencing an access site complication. Femoral access site complications were identified in 77 patients (4.3%) over a 3-year period. Thirty-four of these complications were considered major, requiring blood transfusion or additional invasive treatment. There was a statistically significant difference in total cost ($39,234.84 vs $23,535.32, p = 0.001), total reimbursement ($35,500.24 vs $24,861.71, p = 0.020) and reimbursement minus cost (-$3734.60 vs $1326.39, p = 0.011) between the complication and control cohorts in elective procedures, respectively. Although occurring relatively infrequently, femoral artery access site complications increase the cost of care for patients undergoing neurointerventional procedures; how this influences the cost effectiveness of neurointerventional procedures warrants further investigation.

Evaluation of intracranial stenting in a simulated training and assessment environment for neuroendovascular procedures.

Given the inherent complexity of neurointerventional procedures and the associated risks of ionizing radiation exposure, it is crucial to prioritize ongoing training and improve safety protocols. The aim of this study is to assess a training and evaluation in-vitro environment using a vascular model of M1 stenosis, within a clinical angiography suite, without relying on animal models or X-ray radiation. Using a transparent model replicating M1 stenosis, we conducted intracranial stenting procedures with four different setups (Gateway & Wingspan, Gateway & Enterprise, Neurospeed & Acclino, and Pharos Vitesse). A video camera was integrated with the angiography system's monitor for real-time visualization, while a foot switch was employed to simulate live fluoroscopy. Three neuroradiologists with varying levels of expertise performed each procedure for three times. The total duration of fluoroscopy as well as the time from passing the stenosis with the wire to completion of the procedure were recorded using a dedicated software designed for this experimental setup. Compared to the Gateway & Wingspan procedure, the total fluoroscopy time reduced significantly with the Gateway & Enterprise, Neurospeed & Acclino, and Pharos Vitesse procedures by 51.56 s, 111.33 s, and 144.89 s, respectively (p < 0.001). Additionally, physicians with under 2 years and over 5 years of experience reduced FT by 62.83 s and 106.42 s, respectively, (p < 0.001), compared to a novice physician. Similar trends were noted for the time of wire distal to stenosis, with significant reductions for Neurospeed & Acclino and Pharos Vitesse compared to both Gateway & Wingspan as well as Gateway & Enterprise (all p < 0.001). Procedures requiring wire exchange maneuvers exhibited nearly twice the fluoroscopy time in comparison to balloon-mounted stenting or stent-placement via PTA balloon catheters. The more experienced neuroradiologist demonstrated significantly quicker performance in line with expectations in a real-life clinical setting, when compared to the less experienced interventionalist. This in-vitro setup allowed the evaluation of alternative technical approaches and differences in experience of operators without the use of animal models or X-ray. The setup combines advantages of simulators and silicone vessel models in a realistic working environment.

Trends in Dual Antiplatelet Therapy Use for Neurointerventional Procedures for the Management of Intracranial Aneurysms.

The use of periprocedural dual antiplatelet therapy (DAPT) has significantly evolved along with innovations in the endovascular management of intracranial aneurysms. Historically, aspirin and clopidogrel have been the most commonly employed regimen due to its safety and efficacy. However, recent studies highlight the importance of tailoring DAPT regimens to individual patient characteristics which may affect clopidogrel metabolism, such as genetic polymorphisms. In the present report, a systematic review of the literature was performed to determine optimal antiplatelet use with flow diverting stents, intracranial stents, intrasaccular devices, and stent-assisted coiling. Studies were analyzed for the number of aneurysms treated, DAPT regimen, and any thromboembolic complications. Based on inclusion criteria, 368 studies were selected, which revealed the increasing popularity of alternative DAPT regimens with the aforementioned devices. Thromboembolic or hemorrhagic complications associated with antiplatelet medications were similar across all medications. DAPT with ticagrelor, tirofiban, or prasugrel are effective and safe alternatives to clopidogrel and do not require enzymatic activation. Further clinical trials are needed to evaluate different antiplatelet regimens with various devices to establish highest-level evidence-based guidelines and recommendations.