Total Occlusion Rate Research Articles

Outcome study of the pipeline embolization device for treatment of intracranial aneurysms at a single UK institution

Background: The introduction of flow-diverting stents in the last decade provides an alternative endovascular treatment choice in selected intracranial aneurysms. This retrospective analysis of a UK centre’s experience provides insight into clinical and radiographic outcomes.Methods: Electronic patient records, diagnostic and procedural images and written procedural records for patients treated with the PED between August 2009 and April 2014 were reviewed. Follow-up TOF MRA was performed after treatment. Clinical and radiographic outcomes were analyzed and compared with other PED studies.Results: Twenty-nine patients with 30 attempted PED treatments were reviewed representing 3.5% of the treated aneurysm patient cohort. 63.6% (21/33) of the aneurysms were wide-necked (>4 mm), 60.6% (20/33) were large or giant (≥10 mm). The mean aneurysm sac diameter was 12.0 mm; the mean neck width was 4.5 mm. Mortality and morbidity rates were 3.3% and 10.0%, respectively. The total adequate occlusion rate was 78.1% (25/32) at 18 months. The neck width of aneurysms with residual sac filling and complete occlusion differed significantly (p = 0.04).Conclusions: Highly selected aneurysms treated with a PED in a UK centre have similar occlusion and complication rates when compared to non-UK studies. Again, it appeared that delayed aneurysm rupture remained a risk for PED treatment in large or giant aneurysms. Follow-up with TOF MRA gave similar occlusion results compared to those obtained with DSA in other studies. The influence of neck size on occlusion rate should be examined in future PED studies.

Evaluation of ischemic lesion prevalence after endovascular treatment of intracranial aneurysms, as documented by 3-T diffusion-weighted imaging: a 2-year, single-center cohort study.

OBJECTIVE Even though published data exist concerning the prevalence of ischemic lesions detected by diffusion-weighted imaging (DWI) following endovascular treatment of intracranial aneurysms, a single-center cross-evaluation of the different endovascular techniques has been lacking. The authors sought to prospectively evaluate the prevalence and clinical significance of ischemic lesions occurring after endovascular treatment of intracranial aneurysms and to compare the safety and effectiveness of a broad spectrum of currently accepted endovascular techniques in a single-center setting. METHODS This was a prospective cohort study involving consecutive patients treated for intracranial aneurysms exclusively by endovascular means, excluding treatments in the acute rupture phase, in a center featuring an endovascular-only treatment policy for intracranial aneurysms. All patients underwent MRI, including a 3-directional DWI sequence, before treatment, 24 hours postprocedure, and 6 months following endovascular embolization. Selective angiography was performed at 6 months' follow-up. RESULTS From January 2012 through December 2013, 164 aneurysms were treated in 128 consecutive patients. Endovascular techniques included coiling (14.6%), balloon-assisted coiling (20.1%), stent-assisted coiling (3.7%), low-profile stent-assisted coiling, flow diversion (38.4%), and very complex treatments (6.1%) involving 2 stents in Y or T configurations. On postprocedure MRI, the rates of occurrence of new DWI-positive lesions were 64.3% for coiling, 54.5% for remodeling, 61.1% for stent-assisted coiling, 53.7% for flow-diverting stents, and 75% for very complex treatments (p = 0.4962). The 6-month procedure-related morbidity and mortality rates were 6.25% and 0%, respectively. At 6 months' follow-up, 93% of the patients had modified Rankin Scale (mRS) scores of 0-2. Very complex treatments offered a higher complete occlusion rate (100%) than all other techniques (66.7%-88.9%). Age and length of procedure were independent factors for DWI lesion occurrence. The diameter of DWI lesions on 24-hour postprocedure MRI was positively correlated with mRS score at discharge. Among the DWI-positive lesions measuring less than 2 mm in diameter on the 24-hour MRI, 44.12% had regressed at 6 months. CONCLUSIONS Procedure-related DWI lesions are far more often encountered in silent forms than they are clinically evident. They do not seem to be significantly correlated with procedure-related complications, nor do they seem to impair clinical outcome, regardless of the endovascular technique. Small lesions (< 2 mm in diameter) may regress within 6 months. The use of the most adapted technique, in terms of aneurysm configuration, results in significant total occlusion rates, with acceptable safety.

Short-Term and Midterm Follow-Up of Transthoracic Device Closure of Atrial Septal Defect in Infants

The purpose of this study was to outline the safety and feasibility of transthoracic device closure of an atrial septal defect (ASD) with a domestic occluder in infants. Sixty-eight infants underwent transthoracic device closure of an ASD at Union Hospital, Fujian Medical University, Fuzhou, China from January 2010 to January 2015. All relevant clinical data were recorded and analyzed. All patients were invited to undergo contrast transthoracic echocardiography for 12 to 60 months after ASD closure, and telephone interviews were conducted with the infants' parents to evaluate the patients' clinical status further. All patients had successful ASD occlusion using this approach. The most frequent complication was transient cardiac arrhythmia, which was easily treated or automatically recovered during the perioperative period. During the follow-up period, no recurrence, thrombosis, device embolization, valve damage, device failure, or death was reported. The total occlusion rate was 100% in the 12months of follow-up, and all patients showed significant improvement in their clinical status. From transthoracic echocardiographic data, intracardiac structure and cardiac function were significantly improved at follow-up. Transthoracic device closure of an ASD with a domestic occluder in infants is a safe and feasible technique. The short- and medium-term follow-up results were satisfactory, but long-term follow-up is required to assess the safety and feasibility of this method in infants more accurately.

Anterior accessory great saphenous vein treated with endovenous laser

Introduction Endovenous laser ablation of great saphenous vein (GSV) represents well established technique of radical therapy of varicose veins of lower extremities with excellent long-term results. However, the laser ablation of anterior accessory GSV (AAGSV) remains infrequent in everyday surgical practice. This study assesses the efficacy of this unusual procedure. Material and methods From April 2003 to June 2014, we performed endovenous laser ablation of AAGSV in 147 patients (31 men and 116 women). In total, 173 AAGSV procedures were done. Before surgery, all patients were assessed with colour flow duplex ultrasonography and reflux pattern and diameter of the truncal vein (3.5 to 22.8 mm) were recorded. The endovenous procedures were performed using 980 nm diode or 1320 nm Nd:YAG lasers combined with 600 microns bare fiber. In the follow-up (1 month to 10 years postop), patients were asssessed clinically and with duplex ultrasound. Results No deep venous thrombosis, nor pulmonary embolism were recorded. In majority of patients, we found bruising and/or indurations along the treated veins which resolved within 2 to 3 weeks. Twice, the neovascularisation was found in the groin and the total occlusion rate was 92%. Conclusion Even technically more difficult and delicate, endovenous laser therapy of AAGSV can be performed safely and finally with excellent results comparable to well established ablation of GSV.

Comparative study of the transcatheter and transthoracic device closure treatments for atrial septal defect: A Chinese single-institution experience.

The purpose of this study was to compare patient populations, safety, feasibility, complications, and total costs of the transcatheter and transthoracic device closure treatments for secundum atrial septal defect.From January 2014 to December 2014, we enrolled 155 patients with secundum atrial septal defects in our hospital. The patients were divided into 2 groups: the 70 patients in group A underwent transcatheter device closure, and the 85 patients in group B underwent transthoracic intraoperative device closure with a right lateral mini-thoracotomy.In group A, the total occlusion rate was 94.3% immediately after the operation, 100% at 3 months, and 100% at 12 months of follow-up; the group A results were not statistically different from the group B results (94.1%, 98.8%, 98.8%, respectively). There was a statistically significant difference in the minor complication rate (P < 0.05), and there were no reported deaths. There was a greater indicated scope using the transthoracic closure device to treat atrial septal defects. In our comparative study, the patients in group B had longer intensive care unit stays and hospital stays than group A (P < 0.05).Both of the device closure treatment options for secundum atrial septal defect are safe and feasible. The transcatheter device closure approach has the advantages of more cosmetic results, less trauma, and a shorter hospital stay than the transthoracic approach. On the contrary, the transthoracic closure device is an economical alternative choice, particularly for patients who are not eligible for the transcatheter closure device.

Midterm results of T-stent-assisted coiling of wide-necked and complex intracranial bifurcation aneurysms using low-profile stents.

OBJECTIVE Coiling of wide-necked and complex bifurcation aneurysms frequently requires implantation of double stents in various configurations. T-stent-assisted coiling involves the nonoverlapping implantation of 2 stents to protect the daughter vessels of bifurcation and is followed by coiling of the aneurysm. The authors studied the feasibility, efficacy, and safety of the T-stent-assisted coiling procedure as well as the midterm angiographic/clinical outcomes of patients with wide-necked bifurcation intracranial aneurysms treated using this technique. METHODS The authors retrospectively identified patients with wide-necked bifurcation intracranial aneurysms treated using double-stent-assisted coiling with a T-stent configuration. RESULTS Twenty-four patients with 24 aneurysms and a mean of age of 51.91 years were identified. The most common locations were the middle cerebral bifurcation (45.8%) and anterior communicating artery (35.7%). T stentings were performed using low-profile stents. The procedures were performed with a technical success rate of 95.8%, and an immediate total occlusion rate of 79.2% was achieved. We observed periprocedural complications in 16.7% of cases and a delayed thromboembolic event in 4.2%. The complications caused permanent morbidity in 1 patient (4.2%). No deaths occurred. The mean angiographic follow-up duration was 9.3 months. The total occlusion rate at the last follow-up was 81.2%. The recanalization rate was 4.5%. Modified Rankin Scale scores of all patients at the last follow-ups were between zero and 2. CONCLUSIONS T-stent-assisted coiling using low-profile stents is a feasible, effective, and relatively safe endovascular technique used to treat wide-necked and complex intracranial aneurysms. The midterm angiographic and clinical outcomes are outstanding.

Duplex Guided Foam Sclerotherapy Versus Surgery in Management of Primary Varicose Veins

Background: Varicose veins is a major problem among adult population. It has a major effect on life quality as well as healthcare system resources, we aim in this study to compare ultrasound guided foam sclerotherapy (UGFS) with surgery in management of primary varicose veins patients and to measure patients’ satisfaction with either modalities. Methods: 100 lower limbs of 100 patients with great saphenous vein (GSV) incompetence were prospectively randomized to undergo either surgical treatment or foam sclerotherapy. Clinical, etiological, anatomical and pathophysiological (CEAP) Classification and the Venous Clinical Severity Score (VCSS) were completed and investigated with a follow-up period of 1 year. Results: Total occlusion of great saphenous vein (GSV) was 88% in foam group as well as in the surgery group, recurrence rate in the foam group was 6% as well as in surgery group. Patient satisfaction at 1 year was 94% in foam group while in surgery group it was 90%. There were no statistical significant differences in follow up regarding VCSS, recurrence, patient satisfaction between both groups at 1 month, 6 months and 1 year (p value>0.001). Conclusion: Surgical treatment and UGFS achieved elevated rates of total occlusion of GSV incompetence with no significant difference. Both treatments led to significant improvements in VCSS, demonstrating improvements in clinical outcomes. UGFS is a valid noninvasive modality in management of great saphenous vein incompetence and is comparable to surgery.

Preventing intraluminal occlusion in peripherally inserted central catheters.

Peripherally inserted central catheters (PICCs) are used in a variety of specialties. Infective and thrombotic complications are widely reported but little has been written about the complications of persistent withdrawal occlusion (PWO) or complete luminal occlusion in PICCs. An audit was conducted of all patients who had a PICC in situ for a 6-week period, using a combination of reviewing clinical documentation and local departmental databases, physical review of inpatients and discussion with the relevant clinical nurse specialists in haematology, oncology, outpatient antibiotic therapy and the vascular access team, to determine the degree of PWO or occlusion but also to review possible financial implications in the introduction of a more expensive product. It was difficult to determine a rate for either PWO or complete occlusion owing to the diversity of the patient cohort and the tertiary nature of the organisation; the occlusion rate was estimated at 5%, but there was general agreement this was underestimating the problem. A needle-free connector was subsequently introduced for all PICCs in haematology, oncology and hepatobiliary services. Following the change in needle-free connector, 180 PICCs were inserted by the vascular access team on one of the organisation's sites over a 12-month period, with a total dwell time of 9702 catheter days (mean: 53.9 days, median: 35 days), a PWO rate of 1/1000 catheter days and total occlusion rate of 0.4/1000 catheter days. The time for insertion to complication of PWO or occlusion ranged from 9 to 144 days. Despite poor baseline data the results suggested the introduction of the bi-directional needle-less connector had a positive impact on the PWO and occlusion rates in PICCs.

N-butyl cyanoacrylate in the treatment of venous insufficiency--the effect of embolisation with ablative polymerisation.

The primary objective of this multicentre prospective observational study was to evaluate the early results of a new non-thermal embolisation method using N-butyl cyanoacrylate in venous insufficiency. A total of 181 patients with a varicose vein diagnosis were treated with the VariClose: Vein Sealing Systems at four different centres. The protocol included physical and colour Doppler ultrasonography examination, venous clinical severity score and quality of life assessment before and after the procedure on days 1 and 7 and at months 1, 3 and 6. Clinical recovery was evaluated by comparing the venous clinical severity score and the quality of life assessment before and after the procedure. In total, 215 embolisation procedures were successfully completed on 181 patients (110 female) with a mean age of 37.6 ± 13.2 years (range 18-72 years). The 215 procedures consisted of 25 bilateral applications on 206 great saphenous veins and 9 small saphenous veins. The average pre-interventional diameter of great saphenous veins was 6.5 ± 1.4 mm (4.3-14 mm), and the mean diameter of small saphenous veins was 5.2 ± 1.3 mm (3.8-8.6 mm). The average length of the sealed vein segments was 31.6 ± 6.1 cm (23-70 cm), and the average N-butyl cyanoacrylate usage for the patient was 0.9 ml (0.7-2.1 ml). The procedural occlusion rate was 100%. Post-operative pain was observed in 11 patients (6.1%), and thrombophlebitis was observed in 1 patient (0.5%). No total recanalisation was observed. Five (2.7%) partial recanalisations were observed at the 6 month follow-up. The 6 month total occlusion rate was 97.2%. This new tumescent-free non-thermal embolisation method can be applied safely with high success rates.

A novel maneuver to facilitate retrograde wire externalization during retrograde chronic total occlusion percutaneous coronary intervention

Although the retrograde approach has improved the success rate and procedural efficiency of chronic total occlusion (CTO) percutaneous coronary intervention (PCI), it can still be challenging and time-consuming. We introduce a novel technique that aims to facilitate the critical step of retrograde wire externalization during reverse controlled antegrade and retrograde tracking and dissection (CART), which we named DRAFT (Deflate, Retract and Advance into the Fenestration Technique). DRAFT is performed by simultaneous retraction of the deflating antegrade balloon (after inflation in the subintimal space) and advancement of the retrograde looped wire in the same plane through the transient fenestrations created by reverse CART, in order to cross through the fenestrated dissection flap before its collapse. The retrograde wire is then quickly and easily advanced into the antegrade guiding catheter. DRAFT was used in 11 patients (8 with right coronary artery and 3 with left anterior descending artery CTOs). Several different guidewires were used, since this technique does not need any specific wire to be performed. DRAFT was successful in all cases, after at most five attempts. CTO PCI was then completed as per standard retrograde practice. No complications occurred. DRAFT is a versatile approach that allows easy and quick re-entry of the retrograde wire into the true lumen during reverse CART. It can be performed with a variety of guidewires and is feasible both in the left and right coronary arteries. © 2016 Wiley Periodicals, Inc.

Long-term MACCE Rate after Retrograde Compared to Antegrade Recanalization of Chronic Total Coronary Occlusions

Background: The recanalization success rate of chronic total occlusion (CTO) percutaneous coronary interventions (PCI) can be increased by the retrograde approach. However, the long-term outcome of patients undergoing retrograde procedures is unknown. Aim: We aimed to evaluate the long-term MACCE (major adverse cardiac and cerebrovascular event) rate (death, myocardial infarction, coronary artery bypass surgery and stroke) in patients after retrograde versus antegrade CTO-PCI. Methods and results: In a prospective single center study from January 2008 to June 2012, 396 consecutive patients with CTO´s (≥ 3 months old) were enrolled. Mean age was 63.4 ± 10.3 years, 86.4% were male. The recanalization success rate of the total patient cohort was 88.6%. The retrograde PCI, only attempted after a failed antegrade intervention, was performed in 18% (n = 71) of patients. Long-term MACCE rate (mean follow up 2.3 ± 1.6 years) was significantly higher in the unsuccessful compared to the successful CTO-PCI group (23.1% versus 9.4%, p = 0.01) and this was also the case in the subgroup of antegrade CTO-PCI. In the retrograde subgroup, however, procedural success had no impact on outcome. As a possible explanation for this surprising finding, patients with unsuccessful retrograde CTO-PCI had a significantly better collateral connection compared to patients with an unsuccessful antegrade approach. Conclusions: Long-term MACCE rate after unsuccessful recanalization was significantly higher which was driven by a higher MACCE rate after unsuccessful versus successful antegrade approach. In contrast, procedural success in the retrograde group had no impact on outcome.

Analysis of Plaque Composition in Coronary Chronic Total Occlusion Lesion Using Virtual Histology-Intravascular Ultrasound.

Background and ObjectivesSuccess rates of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have recently been reported to range from 80% to 90%. A better understanding of the pathologic characteristics of the CTO lesion may helpful to improving CTO PCI success rates. We evaluated the CTO lesion in patients with stable angina (SA) by virtual histology-intravascular ultrasound (VH-IVUS).Subjects and MethodsThe study population consisted of 149 consecutive patients with SA underwent VH-IVUS examination. We analyzed demographic and VH-IVUS findings in 22 CTO patients (17 males; mean, 62.3 years old) compared with 127 non-CTO patients (82 males; mean, 61.3 years old).ResultsA significantly lower ejection fraction (57.6±13.0% vs. 65.4±8.8%, p=0.007) was detected in the CTO group compared with the non-CTO group. Reference vessel lumen area of the proximal and distal segment was significantly less in CTO group than in non-CTO group. The lesion length of the CTO group was significantly longer than those of the non-CTO group (24.4±9.6 mm vs. 17.2±7.4 mm, p<0.001). Total atheroma volume (224±159 mm3 vs. 143±86 mm3, p=0.006) and percent atheroma volume (63.2±9.6% vs. 55.8±8.5%, p=0.011) of the CTO group were also significantly greater than those of non-CTO group. However, the lesion length adjusted plaque composition of the CTO group was not significantly different compared with that of the non-CTO group.ConclusionCTO lesions had a longer lesion length and greater plaque burden than the non-CTO lesion in patients with SA. However, lesion length adjusted plaque composition showed similar between the two groups. These results support that plaque characteristics of CTO lesions are similar to non-CTO lesions in patients with SA.

Flow Diversion in Middle Cerebral Artery Aneurysms: Is It Really an All-Purpose Treatment?

The outcome of flow diversion for middle cerebral artery (MCA) aneurysms, one of the most common sites for intracranial aneurysms, has not been defined thoroughly. We assessed our outcomes in MCA aneurysms (MCAAs) treated by flow diversion, i.e., with either dedicated flow diverters or telescopic stents. Patients with MCAAs were treated by flow diversion if surgical or other endovascular treatment modalities had failed or were deemed likely to fail. Angiographic and clinical outcome of these patients was assessed retrospectively. Aneurysm location on MCA was defined as M1 segment, "true bifurcation" (classical bifurcation of MCA into superior and inferior trunks), "variant bifurcation" (bifurcation of early frontal or early/distal temporal branches), or M2 segment. Aneurysm morphology was classified as saccular versus dissecting/fusiform. Treatment was attempted in 29 MCAAs. Technical failure rate was 3.4% (1/29). Thirteen of aneurysms were fusiform. Of the bifurcation aneurysms, most (10/16) were the variant type. Overall and procedure-related mortality/permanent morbidity rates were 10.3% (3/29) and 3.5% (1/29). Total occlusion rates (mean angiographic follow-up 10.3 months) for saccular and fusiform aneurysms were 40% and 75%, respectively. In bifurcation aneurysms, occlusion was strongly associated with side-branch occlusion (P < 0.005). In this series, flow diversion for the treatment of MCAAs was safe, was effective in the treatment of fusiform MCAAs, and was not as effective at mid-term for MCA bifurcation aneurysms. Unsatisfactory occlusion rate in bifurcation aneurysms likely results from residual filling of the aneurysms in cases in which the jailed side branch remains patent.

Positive correlation between occlusion rate and nidus size of proton beam treated brain arteriovenous malformations (AVMs)

Background. Proton beam radiotherapy of arteriovenous malformations (AVM) in the brain has been performed in Uppsala since 1991. An earlier study based on the first 26 patients concluded that proton beam can be used for treating large and medium sized AVMs that were considered difficult to treat with photons due to the risk of side effects. In the present study we analyzed the result from treating the subsequent 65 patients.Material and methods. A retrospective review of the patients’ medical records, treatment protocols and radiological results was done. Information about gender, age, presenting symptoms, clinical course, the size of AVM nidus and rate of occlusion was collected. Outcome parameters were the occlusion of the AVM, clinical outcome and side effects.Results. The rate of total occlusion was overall 68%. For target volume 0–2cm3 it was 77%, for 3–10 cm3 80%, for 11–15 cm3 50% and for 16–51 cm3 20%. Those with total regress of the AVM had significantly smaller target volumes (p < 0.009) higher fraction dose (p < 0.001) as well as total dose (p < 0.004) compared to the rest. The target volume was an independent predictor of total occlusion (p = 0.03). There was no difference between those with and without total occlusion regarding mean age, gender distribution or symptoms at diagnosis. Forty-one patients developed a mild radiation-induced brain edema and this was more common in those that had total occlusion of the AVM. Two patients had brain hemorrhages after treatment. One of these had no effect and the other only partial occlusion from proton beams. Two thirds of those presenting with seizures reported an improved seizure situation after treatment.Conclusion. Our observations agree with earlier results and show that proton beam irradiation is a treatment alternative for brain AVMs since it has a high occlusion rate even in larger AVMs.

Endovenous laser ablation treatment with 980 nm diode laser for saphenous vein insufficiency: 6 months follow up results.

Superficial venous insufficiency is a common problem associated with varicose veins which, if untreated, may progress to venous ulceration. Endovenous laser ablation (EVLA) is a new, minimally invasive method for management of superficial venous insufficiency and varicose veins. The aim of this study was to demonstrate the effectiveness of 980 nm EVLA for treatment of symptomatic saphenous venous insufficiency and to present its early outcomes. Thirty-eight great saphenous veins and 5 small saphenous veins in 40 patients with saphenofemoral reflux were treated with 980 nm diode endovenous laser equipment. The diameter and length of the vein treated, total laser energy and energy density (Joules/cm) delivered were recorded. To determine the severity of the venous disease Venous Clinical Severity Score (VCSS) and Visual Analogue Scale (VAS) were used. Patients were followed up for 6 months after the procedure. Complications were recorded prospectively. Forty-three saphenous veins in 40 patients were treated. The mean age of the patients was 39.9 (range 21-72) years. The mean diameter and length of the veins were 4.9 mm (range, 3.5 to 8.5 mm) and 30.2 cm (range, 16 to 50 cm), respectively. At 6 months follow-up, total occlusion rate was 95.4% (41/43), and recanalization rate was 4.6%. Significant decrease was observed for VCSS and VAS scores after the procedure. No major complication was detected. EVLA treatment for superficial venous insufficiency is safe and can be carried out under local anaesthesia in an outpatient setting with good patient satisfaction and low complication rates.

Treatment of ruptured vertebral artery dissecting aneurysms distal to the posterior inferior cerebellar artery: stenting or trapping?

The treatment of ruptured vertebral artery dissecting aneurysms (VADAs) continues to be controversial. Our goal was to evaluate the safety, efficacy, and long-term outcomes of internal trapping and stent-assisted coiling (SAC) for ruptured VADAs distal to the posterior inferior cerebellar artery (supra-PICA VADAs), which is the most common subset. A retrospective review was conducted of 39 consecutive ruptured supra-PICA VADAs treated with internal trapping (n = 20) or with SAC (n = 19) at our institution. The clinical and angiographic data were retrospectively compared. The immediate total occlusion rate of the VADAs was 80 % in the trapping group, which improved to 88.9 % at the follow-ups (45 months on average). Unwanted occlusions of the posterior inferior cerebellar artery (PICA) were detected in three trapped cases. Incomplete obliteration of the VADA or unwanted occlusions of the PICA were detected primarily in the VADAs closest to the PICA. In the stenting group, the immediate total occlusion rate was 47.4 %, which improved to 100 % at the follow-ups (39 months on average). The immediate total occlusion rate of the VADAs was higher in the trapping group (p < 0.05), but the later total occlusion was slightly higher in the stenting group (p > 0.05). Our preliminary results showed that internal trapping and stent-assisted coiling are both technically feasible for treating ruptured supra-PICA VADAs. Although not statistically significant, procedural related complications occurred more frequently in the trapping group. When the VADAs are close to the PICA, we suggest that the lesions should be treated using SAC.

Brain AVM/Fs: What is the Role of the Combined Treatment Strategies?

Cerebral Arteriovenous Malformations (AVM) are complex vascular formations, variable in size and angioarchitecture and they may locate at any part of the brain. They may present with epilepsy or focal neurological signs and occasionally they are discovered incidentally. They may also rupture, creating intracranial hemorrhage associated with considerable morbidity and mortality. As a consequence these lesions should be, most of the time, be treated. There are three treatment options: surgery, embolization and radiosurgery. What treatment modality is best for each particular case depends on the size, location, age and clinical presentation (i.e., hematoma) of the lesion. Two and sometimes three treatment modalities can be used in combination for a successful treatment. Since 1999 until 2013, 423 patients have been treated in our department. A total of 608 interventions were performed (average: 1.5 procedures per patient). The most common treatment was embolization either alone or in combination with surgery and more often radiosurgery. The total occlusion rate that was accomplished by embolization alone was 36%. Most AVM remnants after embolization were treated with γ-knife radiosurgery. The overall occlusion rate of the combined embolization/γ-knife treatment is 87% (90% for lesion diameter shorter than 3 cm, 82% for diameter longer than 3 cm). In this series pre-radiosurgical embolization was performed with histoacryl and it was targeted to volume reduction. This was the reason the therapeutic result of radiosurgery was facilitated by pre-radiosurgical embolization. Surgical treatment either alone or in combination with pre-operative embolization results in total occlusion of brain AVMs, with low morbidity (no mortality in this surgical series). It is important to emphasize that meticulous selection of the surgical cases was performed (up to Spetzler and Martin grade III). Morbidity/mortality associated to AVM treatment were post-embolization bleeding or ischemia, radiation edema and/or necrosis. One post surgical bleeding was encountered in this series. In conclusion, combined treatment of brain AVMs results in very successful therapeutic management of these lesions. If meticulous selection of treatment strategies is performed for every single patient, complication rates will keep at a satisfactory low rate.

Retraction Note: Transcatheter closure of perimembranous ventricular septal defects (VSD) with VSD occluder: early and mid-term results.

Results of perimembranous ventricular septal defects (pmVSD) transcatheter closure have been reported in the literature, mostly with the Amplatzer VSD device (muscular or eccentric) (AGA Medical Corp., Golden Valley, MN, USA). However, the data of percutaneous closure of pmVSD with VSD occluder (VSD-O) made in China are still limited. We sought to analyze the safety, efficacy, and follow-up results of percutaneous closure of pmVSD with VSD-O made in China. Seventy-eight patients underwent percutaneous closure of pmVSD at our institution between February 2005 and June 2007. A VSD device made in china (Huayishengjie Medical Corp., Beijing, China) was used in all subjects. The mean age at closure was 11 years (range 2.5–44 years). The attempt to place the device was successful in 74 patients (94.9%). The median device size used was 8 mm (range 5–16 mm). No deaths occurred. Total occlusion rate was 62.8% at completion of the procedure, rising to 87.2% at discharge and 99% during the follow-up. A total of eight early complications occurred (10.3%), but in all subjects these were transient. The median follow-up was 32 months. The most significant complication was complete atrioventricular block (cAVB) in the early phase (five subjects, 6.4%) and during the follow-up (one subject, 1.3%), and there was no need for pacemaker implantation in six subjects. Logistic regression analysis showed that the only variable significantly associated with the occurrence of this complication was age at the time of the procedure (p = 0.025; OR 0.22). All subjects experiencing this problem were <5 years old. Percutaneous pmVSD closure used VSD-O made in China is associated with excellent success and closure rates, no mortality, and low morbidity. Nowadays, pmVSD percutaneous closure is a valuable alternative to surgery. Longer follow-up data and improvements in device characteristics are needed to reduce the risk of cAVB.

Radiofrequency Ablation as First-line Treatment of Varicose Veins

Endovascular radiofrequency ablation is a minimally invasive method to safely treat symptomatic refluxing varicose veins. A retrospective chart review was used to determine patient demographics, disease severity, treatment algorithm, and outcome in patients who underwent radiofrequency ablation of symptomatic refluxing veins that had failed conservative management. Statistical analysis was done using GraphPad Demo Version (San Diego, CA). Two hundred forty-one limbs in 179 patients (average age, 53 years; 73% females, 27% males) were treated. Preprocedure Clinical Etiological Anatomic and Pathologic (CEAP) scores were C2s: 236, C3s: 4, and C5s:1. Procedures were performed in the office using tumescent anesthetic; all patients could ambulate immediately after the procedure. Postprocedure total occlusion (TO) rate was seen in 93 per cent of limbs (223 limbs) at 3 months and 91 per cent of limbs (220 limbs) at 12 months posttreatment. No relationship was found between patients who did not have total occlusion and age, sex, diameter of veins, CEAP scores, preoperative reflux time, and volume of tumescent anesthetic (P > 0.05). The VNUS procedure is an in-office, minimally invasive procedure with a low complication rate and quick recovery. Total occlusion rates are high and there is improvement in disease severity after treatment.

Evolving role of endovascular treatment for MCA bifurcation aneurysms: case series of 184 aneurysms and review of the literature

Objective: This study evaluates the role of endovascular therapy for middle cerebral artery (MCA) aneurysms and its evolution over time. We are reporting a large case series of 184 MCA aneurysms and comparative analysis of the literature.Methods: This was a retrospective review of a prospectively maintained database including all patients with MCA bifurcation aneurysms embolized between 2000 and 2013. There were 184 aneurysms in 166 patients, with 71 ruptured and 113 nonruptured aneurysms.Results: Stent assistance was required in 70 cases (38·0%) and 3 cases (1·6%) required ‘Y’ stenting. The initial rate of total aneurysm occlusion was 59·8% and at delayed follow up was 90·1%. Seven embolizations resulted in thrombo-embolic complications (3·8%), with no cases of aneurysm re-bleeding, wire perforations, or other hemorrhages. Three patients with ruptured aneurysms died of causes unrelated to the embolization, and none with nonruptured aneurysms died in the follow-up period (total mortality 1·6% at 30 days post-procedure). A total of seven aneurysms (3·9%) required retreatment with an average follow up of 41 months. Prior to dedicated aneurysm stents, 68·8% of patients underwent embolization with the remainder surgically treated. Following the introduction of aneurysm stents in 2002, 92·0% of MCA aneurysms treated were embolized.Conclusions: During the past decade we have seen a treatment paradigm shift in MCA aneurysm treatment from surgical treatment to endovascular treatment. Developments in 3D angiography, more compliant balloons, dedicated aneurysm stents, complex coils, and antiplatelet therapy regimes have led to this transition for safe and effective management of these patients.