Postprocedural Stroke Research Articles

Long-term Outcomes of Carotid Artery Stenting: A Single-center Experience.

The long-term prophylactic effect of carotid artery stenting (CAS) remains incompletely elucidated. We evaluated outcomes of CAS at our institution to determine the safety and efficacy of CAS in real-world settings. We retrospectively analyzed 73 patients who underwent CAS from 2006 to 2013. Periprocedural results were compared between asymptomatic and symptomatic carotid stenosis groups. The primary endpoint was a composite of ipsilateral stroke, death, and carotid artery restenosis beyond 30 days and within 5 years after the first procedure. The average age was 72.2 years with a majority of male subjects (84.9%). Twenty-seven patients (37%) were asymptomatic. Incidence of periprocedural adverse events and mRS ≤2 at 30 days after CAS were not significantly different between groups (P = 0.14 and 0.07, respectively). CAS was unsuccessful in three patients and one post-procedural minor stroke occurred. Therefore, 69 patients were included in the long-term study. The rate of occurrence of the primary endpoint was 21.7%. Ipsilateral ischemic stroke occurred in one patient, which was due to cardiogenic embolus. Nine patients died, and cancer was the most frequent cause. Five in-stent restenoses were observed. All patients with restenosis underwent additional CAS without any occurrence of stroke. This study revealed the safety and long-term efficacy of CAS in a real-world setting. Routine follow-up is also important for detecting carotid artery restenosis.

Carotid Artery Stenting: A Single-Center Experience of a Tertiary Care Hospital

Abstract Background: Carotid Artery Stenting (CASt) is a method of carotid revascularization, which has developed rapidly over the last 3 decades. CASt now used as an alternative to endarterectomy. Although excellent results from centers with high-volume experience seem to demonstrate CASt as technically feasible and safe, there is an ongoing debate about the complications in terms of early outcomes in patients. Methods: This study was a retrospective study on patients diagnosed with carotid artery stenosis (CASs). The data collected from Jan 2011 to Dec 2019. The patient data screened for inclusion in the study based on findings from contrast angiography. Primary complications to be assessed were major or minor embolic stroke, cardiac arrest, and death within 30 days of the procedure. Minor stroke, myocardial infarction, acute hypotension and bradycardia, noncerebral bleeding, access-site bleeding were considered secondary outcomes. Results: A total of 77 patients were included in the study with a mean age of 74.4±11.3years. The technical procedure of CASt was 100% successful for all the patients. Overall post-procedural stroke rate at 30 days was 7.7% (six out of 77). One (1.3%) patient died due to cardiac arrest. There were two cases (2.6%) of acute hypotension and bradycardia and one case (1.3%) of Access-site bleeding within 30 days of stent implantation. Comorbid conditions were not significantly (p>0.05) associated with the post- procedural complications in CASt. Conclusion: In this study, we found that CASt is the most reliable technique for CASs and appears feasible and comparatively safe with least post-procedural complications. However, advanced techniques are required to further reduce the death/stroke rate within 30 days of stent implantation. Keywords Carotid artery diseases; Carotid stenosis; Stroke; Risk factor; Atherosclerosis Abbreviations CVDs: Cerebrovascular Diseases; CASt: Carotid Artery Stenting; CASs: Carotid Artery Stenosis; IHD: Ischemic Heart Diseases

Cerebral aneurysms treated with low-profile visualized intraluminal support device (LVIS Jr) Y-stent constructs: Technical experience with a single microcatheter technique.

The LVIS Jr device holds a number of advantages but poses unique technical challenges compared to such, especially, complex multistent constructs. We report our experience with the technical feasibility and early to mid-term outcomes of Y-stent-assisted coiling with the LVIS Jr using a simple, single microcatheter technique. Using a departmental database, we retrospectively reviewed a single surgeon's experience with Y-stent-assisted coiling with LVIS Jr over a three-year period. Eighteen aneurysms in 17 patients were treated over this period. We assessed the technical success of the procedures, the initial and follow-up radiographic success with the modified Raymond-Roy occlusion score and follow-up clinical outcome with the modified Rankin scale. All stents were successfully deployed, and 17 of 18 aneurysms were successfully coiled at the initial treatment for a technical success rate of 94.4%. Of the 17 aneurysms with follow-up imaging, all were modified Raymond-Roy grade 1 or 2. One aneurysm required retreatment for coil compaction and a growing neck. There were two immediate postprocedure symptomatic strokes and one delayed stroke related to antiplatelet non-compliance. The two immediate symptomatic strokes recovered to neurological baseline with no residual deficits by the time of discharge. The long-term morbidity rate was 5.5%. The mortality rate was 0%. All patients had a modified Rankin Scale ≤ 2 at most recent follow-up. Treatment with LVIS Jr Y-stent constructs via a single microcatheter technique is technically feasible with good radiographic and clinical outcomes.

Delayed Stroke after Aneurysm Treatment with Flow Diverters in Small Cerebral Vessels: A Potentially Critical Complication Caused by Subacute Vasospasm.

Flow diversion (FD) is a novel endovascular technique based on the profound alteration of cerebrovascular hemodynamics, which emerged as a promising minimally invasive therapy for intracranial aneurysms. However, delayed post-procedural stroke remains an unexplained concern. A consistent follow-up-regimen has not yet been defined, but is required urgently to clarify the underlying cause of delayed ischemia. In the last two years, 223 patients were treated with six different FD devices in our center. We identified subacute, FD-induced segmental vasospasm (SV) in 36 patients as a yet unknown, delayed-type reaction potentially compromising brain perfusion to a critical level. Furthermore, 86% of all patients revealed significant SV approximately four weeks after treatment. In addition, 56% had SV with 25% stenosis, and 80% had additional neointimal hyperplasia. Only 13% exhibited SV-related high-grade stenosis. One of those suffered stroke due to prolonged SV, requiring neurocritical care and repeated intra-arterial (i.a.) biochemical angioplasty for seven days to prevent territorial infarction. Five patients suffered newly manifested, transient hemicrania accompanying a compensatorily increased ipsilateral leptomeningeal perfusion. One treated vessel obliterated permanently. Hence, FD-induced SV is a frequent vascular reaction after FD treatment, potentially causing symptomatic ischemia or even stroke, approximately one month post procedure. A specifically early follow-up-strategy must be applied to identify patients at risk for ischemia, requiring intensified monitoring and potentially anti-vasospastic treatment.

P3728Impact of residual leaks and device-associated thrombus after left atrial appendage occlusion: long-term transesophageal follow-up and clinical outcome

Abstract Background Standardized transesophageal echocardiography (TEE) data regarding peri-device leaks and thrombus formation after left atrial appendage occlusion (LAAO) are sparse. Criteria to quantify residual leaks seem to appear highly arbitrarily. We therefore examined patients by long-term TEE follow-up after LAAO in a standardized Echo protocol. Methods Our patients were prospectively examined by questionnaires and TEE 6 weeks post-procedurally and ≥12 months after LAAO. TEE was performed according to the Munich consensus document, including multiple TEE views (2D and 3D) and an adequate, lower Nyquist limit (20–30cm/s) to detect low velocity flow. The severity of the leaks were graded as follows: >5mm severe, 3–5mm moderate and 1–2mm mild. Antithrombotic regime was administered according to the PROTECT-AF protocol for the Watchman device in the first 60 patients, and dual antiplatelet therapy for 1–3 months thereafter as well as for the Amplatzer device. Results In total, 107 LAAO were performed in our institution in patients with a mean age of 77 years. Mean CHA2DS2-VASc score was 4.3±1.3, mean HAS-BLED score 2.7±0.9. Mean clinical follow-up duration was 52.8 months, mean TEE follow-up 43.1 months. The overall annual stroke rate was 1.49%. None of the patients with a post-procedural stroke showed an intracardial thrombus by TEE after six weeks, during the event and in long-term FU. In long-term TEE follow-up 46% (n=18/39) had a mild to moderate residual leak and 2.6% (n=1/39) a severe leak >5mm.Two of the patients with a permanently existing leak sustained an ischemic stroke: in the first patient with a peri-device leak of 3mm the stroke occurred 80 months post-procedurally, in the second one with a growing leak from 3 to 6,5mm 25 months post-procedurally, both classified most likely as a cardioembolic stroke. One patient without a leak in long-term TEE FU suffered a stroke 5 years after LAAO (p=0.61). In all three patients antithrombotic regime during the event consisted of ASS alone.Device-associated thrombus was observed in 1.9% (n=2/107) six weeks after the procedure and increased to 15.4% (n=6 out of 39 TEE studies) in long-term FU, all appeared immobile. None of those patients suffered a thromboembolic event. Conclusions In long-term follow up, residual, mostly mild to moderate leaks and device-associated thrombi after LAAO seem to occur occasionally. However, patients with a residual leak or immobile thrombus do not appear to have a higher risk for thromboembolism so far.

5034Is stroke an issue after transcatheter mitral valve repair? A systematic review and meta-analysis

Abstract Background Transcatheter mitral valve repair (TMVR) is a minimally invasive therapeutic procedure used as an alternative to surgery for mitral valve regurgitation in high risk patients. This technique creates a double orifice area, which might be comparable to a mitral prosthesis or mitral stenosis. So far, no strict antithrombotic therapy has been recommended and different post-procedure protocols are being currently applied. Objectives To assess stroke rate after TMVR, comparing it with surgical mitral valve repair (SMVR) and optimal medical treatment (OMT). Methods We systematically searched PubMed, Embase and Cochrane databases, in December 2018, for both interventional or observational studies comparing TMVR with SMVR and/or OMT in the treatment of severe mitral regurgitation. Only studies including data on post-procedure stroke incidence were selected. Two authors independently screened articles for inclusion, risk of bias and data extraction. Random-effects meta-analysis for TMVR, SMVR and OMT were performed. Due to the low number of pooled events, a cumulative meta-analysis was subsequently implemented. The meta-analysis was registered on the Prospero database. Results 15 studies were selected for qualitative analysis and, among these, 10 were included in the quantitative analyses (7 of TMVR vs. SMVR and 3 of TMVR vs. OMT), providing a total of 1881 patients. TMVR patients were older and had higher surgical risk scores than SMVR patients. Groups were homogeneous regarding previous atrial fibrillation rate (pooled OR 1.45 [0.82–2.55]), whereas post-procedure de novo atrial fibrillation was more frequent in SMVR when compared with TMVR (pooled OR 0.20 [0.06–0.7]). Although the pooled stroke rate was numerically lower in the TMVR group, there was no statistically difference in the stroke incidence between TMVR and SMVR (pooled OR 0.49 [0.17, 1.42], p=0.19, I2= 0%) – Panel A. On the other hand, cumulative meta-analysis was able to show a significantly lower stroke rate in TMVR, when compared to SMVR (OR 0.4 [0.40, 0.67], p<0.05). As for TMVR vs. OMT, no difference in stroke rate was identified (pooled OR 1.09 [0.60, 1.97], p=0.79, I2=0%) – Panel B. Forest Plots – Stroke incidence Conclusions Post-procedure TMVR stroke rate was similar to that of patients managed with OMT only. For the same outcome, results favored TMVR when compared with SMVR, which might be related to its lower incidence of post-procedure de novo atrial fibrillation. These findings may prove insightful to future recommendations regarding the conundrum of the best antithrombotic strategy, particularly for patients with atrial fibrillation.

Non-Cardiovascular Comorbidities as Evaluated by Elixhauser Comorbidity Score in Individuals Undergoing TAVR

ABSTRACT Background: To explore the relationship between comorbidity burden and mortality, peri-procedural complications, and length of stay in patients treated with TAVR in the National Inpatient Sample (NIS). Patients undergoing transcatheter aortic valve replacement (TAVR) often have multiple comorbidities. Whilst the impact of individual comorbid conditions on clinical outcomes following TAVR has been previously assessed, the impact of more global measures of comorbidity remains unknown in this cohort. To explore the relationship between comorbidity burden and mortality, peri-procedural complications, and length of stay in patients treated with TAVR NIS. Methods: TAVR procedures were identified between 2011 and 2014 and comorbidities were defined by the Elixhauser classification system (ECS) consisting of 30 comorbidity measures. Endpoints included in-hospital mortality, periprocedural complications, and length of stay. Patients were classified based on their ECS in five categories (ECS I < 0, ECS II = 0, ECS III = 1–5, ECS IV = 6–13, ECS V ≥ 14). Results: A total of 40,604 TAVR patients were identified. Mean age was 81.2 ± 8.5 years. Patients with ECS category V accounted for more than 40% of the cohort and experienced almost a 2.5-fold increase in in-hospital mortality (OR 2.42, 95% CI: 1.28–4.56), acute kidney injury (OR: 6.23, 95% CI: 4.13–9.41), major bleeding (OR: 2.26, 95% CI: 1.71–2.99), post-procedural stroke or TIA (OR: 2.02, 95% CI: 1.08–3.78). It was also associated with a mean 4.14-day increased length of stay (95% CI: 3.67 to 4.65) compared to patients with lower ECS category after adjusting for confounding factors. Conclusions: Our study of over 40,000 TAVRs shows that Elixhauser comorbidity score was independently associated with higher mortality, periprocedural complications, and length of stay. Global comorbidity burden is an important consideration for risk stratification in patients undergoing TAVR.

Comparison of Outcomes After Percutaneous Coronary Interventions in Patients of Eighty Years and Above Compared With Those Less Than 80 Years

Life expectancy in the United States has increased due to advances in health care. Despite increased utilization of percutaneous coronary intervention (PCI), octogenarian patients are less likely to be referred to the catheterization laboratory for coronary interventions. This is in part due to multiple patient co-morbidities and lack of established guidelines. We examined in-hospital clinical outcomes of octogenarian and nonoctogenarian patients who underwent PCI in the United States. Using the National Inpatient Sampling database, we identified all adult patients who are older than 18 years and underwent PCI. Patient were stratified by age into 2 groups, ≥80 years old and <80 years old and in-hospital adverse outcome rates were determined. A total of 11,056,559 patients underwent PCI between the years of 2002 and 2014 and 1,544,563 patients were ≥80 years old (14%). After multivariable adjustment, patients who are ≥80 years old had higher in-hospital mortality (3.3% vs 1.3%, adjusted Odds Ratio, 1.624; 95% confidence interval, 1.602 to 1.647, p <0.0001) and longer length of stay (median length of stay days 3, range 2 to 8 days vs median 2 days, range 1 to 4 days) (p <0.0001). Patients ≥80 years old had a higher rate of cardiopulmonary complications, postprocedural stroke, acute kidney injury, postprocedural thromboembolic complications, and hemorrhage requiring transfusion. There was no difference in vascular complications between the 2 groups. In conclusion, octogenarians who underwent PCI were at increased risk for in-hospital mortality and morbidity compared with nonoctogenarians. The decision to proceed with PCI in this patient population should be individualized, taking into consideration known risk factors and patient's wishes.

Long-term Outcomes of Stenting and Endarterectomy for Symptomatic Carotid Stenosis: A Preplanned Pooled Analysis of Individual Patient Data

A pooled analysis was conducted of four randomized controlled trials with patients randomly assigned between November 2000 and July 2008. Review of the four largest randomized trials (Endarterectomy vs Angioplasty in Patients with Symptomatic Severe Carotid Stenosis [EVA-3S], Stent-Protected Angioplasty vs Carotid Endarterectomy [SPACE], International Carotid Stenting Study [ICSS], and Carotid Revascularization Endarterectomy versus Stenting Trial [CREST]) of carotid artery stenting and carotid endarterectomy (CEA) for treatment of symptomatic carotid stenosis included 4754 patients for analysis. Median follow-up ranged from 2.0 to 6.9 years. After the periprocedural period, annual rates of ipsilateral stroke per person-year were similar between the two treatments. However, the periprocedural and postprocedural stroke risks combined favored CEA with treatment differences equal to 3.2% up to 9 years. Although long-term outcomes continue to favor CEA, the similarity of postprocedural rates suggests that improvements in the periprocedural safety of carotid artery stenting could provide similar outcomes of the two procedures in the future.

Association Between Transcatheter Aortic Valve Replacement and Early Postprocedural Stroke

Reducing postprocedural stroke is important to improve the safety of transcatheter aortic valve replacement (TAVR). This study evaluated the trends of stroke occurring within 30 days after the procedure during the first 5 years TAVR was used in the United States, the association of stroke with 30-day mortality, and the association of medical therapy with 30-day stroke risk. Retrospective cohort study including 101 430 patients who were treated with femoral and nonfemoral TAVR at 521 US hospitals in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry from November 9, 2011, through May 31, 2017. Thirty-day follow-up ended June 30, 2017. TAVR. The rates of 30-day transient ischemic attack and stroke were assessed. Association of stroke with 30-day mortality and association of antithrombotic medical therapies with postdischarge 30-day stroke were assessed with a Cox proportional hazards model and propensity-score matching, respectively. Among 101 430 patients included in the study (median age, 83 years [interquartile range {IQR}, 76-87 years]; 47 797 women [47.1%]; and 85 147 patients [83.9%] treated via femoral access), 30-day postprocedure follow-up data was assessed in all patients. At day 30, there were 2290 patients (2.3%) with a stroke of any kind (95% CI, 2.2%-2.4%), and 373 patients (0.4%) with transient ischemic attacks (95% CI, 0.3%-0.4%) . During the study period, 30-day stroke rates were stable without an increasing or decreasing trend in all patients (P for trend = .22) and in the large femoral access subgroup (P trend = .47). Among cases of stroke within 30 days, 1119 strokes (48.9%) occurred within the first day and 1567 (68.4%) within 3 days following TAVR. The occurrence of stroke was associated with a significant increase in 30-day mortality: 383 patients (16.7%) of 2290 who had a stroke vs 3662 patients (3.7%) of 99 140 who did not have a stroke died (P < .001; risk-adjusted hazard ratio [HR], 6.1 [95% CI, 5.4-6.8]; P < .001). After propensity-score matching, 30-day stroke risk was not associated with whether patients in the femoral cohort were (0.55%) or were not (0.52%) treated with dual antiplatelet therapy at hospital discharge (HR, 1.04; 95% CI, 0.74-1.46) nor was it associated with whether patients in the nonfemoral cohort were (0.71%) or were not (0.69%) treated with dual antiplatelet therapy (HR, 1.02; 95% CI, 0.54-1.95). Similarly, 30-day stroke risk was not associated with whether patients in the femoral cohort were (0.57%) or were not (0.55) treated with oral anticoagulant therapy at hospital discharge (HR, 1.03; 95% CI, 0.73-1.46) nor was it associated with whether patients in the nonfemoral cohort were (0.75%) or were not (0.82%) treated with an oral anticoagulant (HR, 0.93; 95% CI, 0.47-1.83). Between 2011 and 2017, the rate of 30-day stroke following transcatheter aortic valve replacement in a US registry population remained stable.

Long-term Outcome of Angioplasty Using aWingspan Stent, Post-Stent Balloon Dilation and Aggressive Restenosis Management for Intracranial Arterial Stenosis.

To investigate the long-term outcome of stent angioplasty for symptomatic severe intracranial artery stenosis. In this study 95 consecutive patients with intracranial atherosclerotic stenosis (>70%) underwent stent angioplasty using Wingspan stents. The primary endpoints were stroke or death within 30days of the procedure and subsequent stroke attributed to the stented vessel. Disabling stroke was defined as stroke with amodified Rankin scale > 3.Secondary endpoints included transient ischemic attacks, contralateral stroke, nonstroke death, and other events. Patients underwent prestent balloon dilation with or without poststent balloon dilation, close restenosis follow-up, and selective retreatment, as required. The mean follow-up duration was 34.9 ± 23.3months. Primary endpoint events occurred in 23% of the patients. The median infarction volume was 2.6ml, and 11 (68%) of 16 infarctions were <5ml in volume. Disabling stroke occurred in 3% of patients. The primary endpoint rates were 17.9% within 30days and 2.1% from 30days to 1year. Secondary endpoint events occurred in 27.3% of the patients. Mean stenosis was reduced from 76.8 ± 6.1% to 7.5 ± 13.4%. Of 80patients who underwent angiographic follow-up, 11 (14%) experienced restenosis (≥50%) and 7 (9%) exhibited restenosis-related symptoms of transient ischemic attack. The rate of symptomatic restenosis was significantly higher in patients who underwent prestent balloon dilation alone than in patients who underwent prestent and poststent balloon dilation (p = 0.016). The postprocedural stroke rate was similar to that observed in the SAMMPRIS study. Symptomatic restenosis may be reduced by poststent dilation, close angiographic follow-up, and retreatment.

Outcomes of Transcatheter Aortic Valve Replacement in Patients with Carotid Artery Disease

ABSTRACT Background: Stroke is a morbid complication following transcatheter aortic valve replacement (TAVR), and the role of underlying carotid disease (CD) in predicting this complication is unknown. This study was undertaken to evaluate outcomes after TAVR in patients with and without CD. Methods: The study population was extracted from the 2014 Nationwide Readmissions Data (NRD) using International Classification of Disease Ninth-Clinical Modification (ICD-9-CM) codes for TAVR, CD and post-procedural complications to extract the exposure group of TAVR patients with a history of CD. Propensity score matching was used to extract a matched control group (TAVR-C). Study endpoints included all-cause in-hospital mortality, length of stay (LOS), post-procedural stroke, acute myocardial infarction (AMI), acute renal failure (ARF), bleeding, mechanical complications of prosthetic valve, vascular complications (VC), need for a new permanent pacemaker (PPM), and 30-day readmission rates. Results: A total of 636 discharges were included in each group. Both groups were comparable in terms of baseline characteristics and comorbidities. Mean age was 81.1 years and 45% were female. There was no significant difference in all-cause in-hospital mortality (3.8% versus 4.9%, p = 0.34), LOS (8.5 vs. 9.3 days, p = 0.12), post-procedural stroke (3.1% vs. 3.5%, p = 0.75), AMI (3.1% vs. 3.5%, p = 0.75), ARF (18.9% versus 17.5%, p = 0.51), bleeding (36.5% vs. 35.1%, p = 0.59), mechanical complications of prosthetic valve (1.1% vs. 0.8%, p = 0.56), VC (3.8% vs. 4.1%, p = 0.78), PPM (8.0% vs. 9.8%, p = 0.30) or 30-day readmission rate (20.7% vs. 23.8%, p = 0.62). Conclusion: Compared to TAVR-C, TAVR-CD was associated with comparable in-hospital post-procedural stroke and other outcomes.

Prognostic impact of postprocedure stroke volume in patients with low-gradient aortic stenosis

ObjectiveThe effect of postoperative blood flow status on the prognosis of patients with low-gradient severe aortic stenosis (AS) has not been examined. Severe AS is associated with a higher mortality...

Review on Future Targets and Current Trends in Transcatheter Left Atrial Appendage Closure

Atrial fibrillation is cause for a growing burden of thromboembolic stroke. Transcatheter left atrial appendage closure is an alternative to lifelong oral anticoagulation for many patients with nonvalvular atrial fibrillation. Reviewed here are three commonly used devices (Watchman, Amplatzer Cardiac Plug/Amulet, and Lariat) and their key clinical trials, special candidate patient populations, and recent investigations of the impact of post-procedure antithrombotic strategies. Transcatheter left atrial appendage closure devices provide noninferior thromboembolic stroke risk reduction and superior bleeding risk reduction compared with oral anticoagulation in nonvalvular atrial fibrillation. Very recent studies of post-procedure antithrombotic regimens describe a variety of anticoagulant and antiplatelet pharmacotherapies without clear impact on device-associated thrombus or post-procedure embolic stroke though more study is needed. Transcatheter left atrial appendage closure is a viable alternative to lifelong oral anticoagulation to decrease thromboembolism and bleeding in patients with nonvalvular atrial fibrillation who are at increased risk of adverse event with anticoagulants. Patient populations at risk of bleeding on anticoagulants have been demonstrated to benefit from this technology, but there are several additional benefits of left atrial appendage closure unrelated to bleeding risks for specific patient populations. Data on the optimal short-term (weeks to months) post-procedure antithrombotic regimens is emerging and will play a significant role in how to best treat patients and which patients will benefit most from left atrial appendage closure.

Comparison of postoperative results between carotid endarterectomy and carotid artery stenting for patients with contralateral carotid artery occlusion: A meta-analysis.

Objectives The purpose of this study was to conduct a meta-analysis to systematically compare the safety and efficacy of carotid endarterectomy and carotid artery stenting in contralateral carotid occlusion patients who needed reperfusion. Methods This study retrieved potential academic articles comparing results between carotid endarterectomy and carotid artery stenting for patients with contralateral carotid occlusion from the MEDLINE database, the PubMed database the EMBASE database, and the Cochrane Library from January 1990 to May 2018. The reference articles for the identified studies were carefully reviewed to ensure that all available documents were represented in the study. Results Four retrospective cohort study involving 6252 patients with contralateral carotid occlusion were included in our meta-analysis. During 30-day follow-up, there is significant difference in post-procedure mortality (odds ratio (OR) = 0.476, 95% confidence interval (CI) (0.306–0.740), P = 0.001); no significant differences are not found in post-procedure stroke (risk difference (RD) = 0.002, 95%CI (–0.007 to 0.011); P = 0.631), myocardial infarction (RD = 0.003, 95%CI (–0.002 to 0.008); P = 0.301), and transient cerebral ischemia (RD = 1.059, 95%CI (–0.188 to 5.964); P = 0.948). Conclusions Carotid endarterectomy was associated with a lower incidence of mortality compared to carotid artery stenting for patients with contralateral carotid occlusion. Regarding stroke, myocardial infarction, and transient ischemic attack, there was no significant difference between the two groups. More randomized controlled trials and prospective cohorts are necessary to help further clarify the ideal approach for these patients.

Segment Occlusion vs. Reconstruction-A Single Center Experience With Endovascular Strategies for Ruptured Vertebrobasilar Dissecting Aneurysms.

Objective: Ruptured dissecting aneurysms of the intracranial vertebral arteries exhibit an extraordinarily high risk for morbidity and mortality and are prone to re-rupture. Therefore, early treatment is mandatory to induce stagnation of the critical dynamic mural process. Appropriate endovascular approaches are segment sacrifice and reconstruction, however, both carry specific risks and benefits. To date most studies discuss only one of these approaches and focus on one specific device or technique. Therefore, our study aimed to present our experiences with both techniques, providing a considered approach on when to perform endovascular reconstruction or sacrifice.Materials and Methods: We retrospectively reviewed patients with subarachnoid hemorrhage in our database, suffering from dissecting aneurysms of the intradural vertebral arteries and treated endovascularly in the acute setting. A total of 16 cases were included. Clinical history, radiologic findings and outcomes were analyzed.Results: In 7 patients a reconstructive approach was chosen with 4 of them receiving stent-assisted coiling as primary strategy. One of the 7 patients suffered early re-bleeding due to progression of the dissection and therefore treatment was augmented with implantation of 2 flow diverters. The remaining 2 patients were primarily treated with flow diverters in telescoping technique. In 9 patients a deconstructive approach was followed: 6 patients were treated with proximal coil-occlusion of the V4 segment, 3 patients received distal coiling of the V4 segment. Two patients died (GOS 1) in the subacute stage due to sequelae of recurrent episodes of raised intracranial pressure and parenchymal hemorrhage. Two patients kept severe disability (GOS 3), six patients had moderate disability (GOS 4) and seven patients showed full recovery (GOS 5). None of the patients suffered from a procedural or postprocedural ischemic stroke.Conclusions: In patients with good collateral vascularization, proximal, or distal partial segment sacrifice via with endovascular coil occlusion seems to yield the best risk-benefit ratio for treatment of ruptured dissecting V4 aneurysms, especially since no continued anticoagulation is required and possibly essential surgery remains feasible in this scenario. If possible, PICA occlusion should be avoided—although even proximal PICA occlusion can become necessary, when weighing against the risk of an otherwise untreated ruptured V4 dissecting aneurysm. Contrarily, if the dominant V4 segment is affected, the hemodynamic asymmetry prohibits occlusion and necessitates reconstruction of the respective segment. For this, implants with high metal coverage treating the entire affected segment appear to be the most promising approach.

Technical improvements in carotid revascularization based on the mechanism of procedural stroke.

The benefit of carotid revascularization in patients with severe carotid artery stenosis is hampered by the risk of stroke due to the intervention itself. The risk of periprocedural strokes is higher for carotid artery stenting (CAS) as compared to carotid endarterectomy (CEA). Over the past years, the pathophysiological mechanism responsible for periprocedural stroke seems to unfold step by step. Initially, all procedural strokes were thought to be the result of technical errors during surgical repair: cerebral ischemia due to clamping time of the carotid artery, cerebral embolization of atherosclerotic debris due to manipulation of the atheroma or thrombosis of the artery. Following improvements in surgical techniques, technical skills, new intraoperative monitoring technologies such as angioscopy, and the results of the first large clinical randomized controlled trials (RCT) it was believed that most periprocedural strokes were of thromboembolic nature, while a large part of these caused by technical error. Nowadays, analyses of underlying pathophysiological mechanisms of procedural stroke make a clinically relevant distinction between intra-procedural and postprocedural strokes. Intra-procedural stroke is defined as hypoperfusion due to clamping (CEA) or dilatation (CAS) and embolization from the carotid plaque (both CEA and CAS). Postprocedural stroke can be caused by thrombo-embolisation but seems to have a primarily hemodynamic origin. Besides thrombotic occlusion of the carotid artery, cerebral hyperperfusion syndrome (CHS) due to extensively increased cerebral revascularization is the most reported pathophysiological mechanism of postprocedural stroke. Multiple technical improvements have attempted to lower the risk of periprocedural stroke. The introduction of antiplatelet therapy (APT) has significantly reduced the risk of thromboembolic events in patients with carotid stenosis. Over the years, recommendations regarding APT changed. While for a long time APT was discontinued prior to surgery because of a fear of increased bleeding risk, nowadays continuation of APT during carotid intervention (aspirin monotherapy or even dual APT including clopidogrel) is found to be safe and effective. In CAS patients, dual APT up to three months' postprocedural is considered best. Stent design and cerebral protection devices (CPD) for CAS procedure are continuously under development. Trials have suggested a benefit of closed-cell stent design over open-cell stent design in order to reduce procedural stroke, while the benefit of CPD during stenting is still a matter of debate. Although CPD reduce the risk of procedural stroke, a higher number of new ischemic brain lesions detected on diffusion weighted imaging was found in patients treated with CPD. In patients undergoing CEA under general anesthesia, adequate use of cerebral monitoring (EEG and transcranial Doppler [TCD]) has reduced the number of intraoperative stroke by detecting embolization and thereby guiding the surgeon to adjust his technique or to selectively shunt the carotid artery. In addition, TCD is able to adequately identify and exclude patients at risk for CHS. For CAS, the additional value of periprocedural cerebral monitoring to prevent strokes needs urgent attention. In conclusion, this review provides an overview of the pathophysiological mechanism of stroke following carotid revascularization (both CAS and CEA) and of the technical improvements that have contributed to reducing this stroke risk.

DECREASED REDOX-POTENTIAL AND HYPERPRODUCTION OF SUPEROXIDE ANION IN BLOOD PREDICTS CARDIAC ARRHYTHMIAS AFTER DIRECT SURGICAL MYOCARDIAL REVASCULARIZATION

The aim of investigation was the evaluation of prognostic value of redox-potential decreasing and hyperproduction of superoxide anion in plasma with or without of total pool of pyridine nucleotides decreasing in the in-hospital complications after direct surgical myocardial revascularization. 303 patients (248 male and 48 female), mean age 58,6±6,8 years with diagnosis of ischemic heart disease and sinus rhythm without marked left ventricular dysfunction which undergoing coronary bypass graft surgery were included in the multicentral prospective study. European System for Cardiac Operative Risk Evaluation (EuroScore) and the incidence rates of post-procedural ischemic stroke CHADS2 and CHA2DS2-VASc score were calculated. Total pyridine nucleotide pool, redox-potential, hyperproduction of superoxide anion and activity of NADPH-oxidase in blood plasma were determinate before and one year after cardiac surgery. For statistical analysis the SPSS version 23.0 (SPSS Inc. Chicago, Ill) was used, all variables are expressed as mean±standard deviation (SD). The maximum of appearance of postoperative atrial fibrillation (POAF) developed in 34% patients after 1-2 days from cardiac surgery. In the cohort of patients with POAF complicated with decease of redox-potential NAD/NADH by 23% (р

Temporary oral anticoagulation after MitraClip – a strategy to lower the incidence of post-procedural stroke?

Background: Incidence of stroke within 30 days after percutaneous mitral valve repair using the MitraClip varies from 0.7% and 2.6% between registries. Standard medical treatment after the MitraClip procedure, in the absence of risk factors requiring antithrombotic therapy such as atrial fibrillation, is dual antiplatelet therapy using aspirin and clopidogrel. ESC/EACTS and ACC/AHA surgical guidelines show a Class IIa indication for temporary antithrombotic therapy after mitral valve repair/bioprosthetic valve replacement within the first three months even in patients with no additional risk factors.Methods: 470 patients were treated with the MitraClip receiving oral anticoagulation (Coumadin: INR 2.0–3.0) instead of dual antiplatelet therapy for at least 30 days after the procedure. The incidence of stroke, as well as major adverse events such as bleeding, were analysed in comparison to large registries and multi-centre studies.Results: Incidence of stroke within 30 days was significantly reduced as compared to comparative cohorts (0.2% vs. Median 1.3% [0.7–2.6%]; p < .05). Cardiovascular risk factors such as age, atrial fibrillation, hypertension, diabetes, STS score and prior stroke did not differ significantly between cohorts (ns). Bleeding complications were not increased due to 30 days oral anticoagulation treatment (4.6% vs. Median 7.4% [3.4–13.6%]; ns).Conclusions: Temporary oral anticoagulation might be a strategy to reduce the incidence of stroke within the first 30 days after the MitraClip procedure. Bleeding events were not significantly altered due to temporary oral anticoagulation.

Outcomes of transcatheter aortic valve replacement in patients with mitral valve regurgitation.

IntroductionTranscatheter aortic valve replacement (TAVR) is currently considered a class I indication for patients with severe symptomatic aortic stenosis and high/prohibitive surgical risk.AimWe describe the effect of concomitant mitral valve regurgitation (MR) on post-procedural TAVR outcomes.Material and methodsThe study population was extracted from the 2014 National Readmissions Data (NRD) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for TAVR, MR and post-procedural outcomes. Propensity matching was used to extract a control group of TAVR patients without MR (TAVR-C) to the TAVR with concomitant MR group (TAVR-MR). Study outcomes included in-hospital all-cause mortality, in-hospital post-procedural stroke, acute myocardial infarction (AMI), bleeding, mechanical complications of prosthetic valve, vascular complications (VC), need for new permanent pacemaker implantation (PPM) and 30-day readmission rates.ResultsA total of 1511 patients were identified in each group (mean age: 81.7 years, 49.3% male); the two groups were comparable in terms of baseline characteristics and co-morbidities. When compared to TAVR-C, TAVR-MR was associated with lower post-procedural stroke (3.5% vs. 5.2%, p = 0.03). There was no significant difference between groups in terms of all-cause mortality (4.1% vs. 4.5%, p = 0.59), AMI (3.2% vs. 2.9%, p = 0.59), bleeding (33.4% vs. 35.6%, p = 0.19), mechanical complications of prosthetic valve (2.5% vs. 1.9%, p = 0.31), VC (3.2% vs. 4.4%, p = 0.06), the need for PPM (7.9% vs. 9.1%, p = 0.21) or 30-day readmission rates (19.0% vs. 19.1%, p = 0.95).ConclusionsTAVR-MR was associated with lower post-procedural stroke but comparable other in-hospital outcomes and 30-day readmission rates to TAVR-C.