Risk Of Periprocedural Stroke Research Articles

Management of patent foramen ovale in non-cardiac surgery

Patent foramen ovale (PFO) is a remnant of normal fetal anatomy which may persist into adulthood, mostly asymptomatic. In some adults, PFO may result in a potential for shunting venous thromboembolism to the arterial circulation; less frequently it can cause interatrial, right-to-left shunting of deoxygenated blood. The pathogenesis of several medical conditions is related to the presence of PFO. Some randomized clinical trials have shown evidence of benefit for device closure as compared with medical therapy in patients with cryptogenic stroke. The literature reported several cases of carbon dioxide embolism during general laparoscopic surgery and sometimes stroke after laparoscopic or neurosurgery but there are neither prospective studies addressing these issues, nor randomized clinical trials assessing the effectiveness of pharmacotherapy or interventional procedures at decreasing risk. The European position paper suggests routine monitoring in non-cardiac surgery of patients with a PFO and no actual indications for closure. This article aims to further stratify the risk of periprocedural stroke and paradoxical embolism in this category of patients.

Association of Bovine Arch Anatomy With Incident Stroke After Transcatheter Aortic Valve Replacement.

Acute ischemic stroke complicates 2% to 3% of transcatheter aortic valve replacements (TAVRs). This study aimed to identify the aortic anatomic correlates in patients after TAVR stroke. This is a single-center, retrospective study of patients who underwent TAVR at the Mayo Clinic between 2012 and 2022. The aortic arch morphology was determined via a manual review of the pre-TAVR computed tomography images. An "a priori" approach was used to select the covariates for the following: (1) the logistic regression model assessing the association between a bovine arch and periprocedural stroke (defined as stroke within 7 days after TAVR); and (2) the Cox proportional hazards regression model assessing the association between a bovine arch and long-term stroke after TAVR. A total of 2775 patients were included (59.6% men; 97.8% White race; mean±SD age, 79.3±8.4 years), of whom 495 (17.8%) had a bovine arch morphology. Fifty-seven patients (1.7%) experienced a periprocedural stroke. The incidence of acute stroke was significantly higher among patients with a bovine arch compared with those with a nonbovine arch (3.6% versus 1.7%; P=0.01). After adjustment, a bovine arch was independently associated with increased periprocedural strokes (adjusted odds ratio, 2.16 [95% CI, 1.22-3.83]). At a median follow-up of 2.7 years, the overall incidence of post-TAVR stroke was 6.0% and was significantly higher in patients with a bovine arch even after adjusting for potential confounders (10.5% versus 5.0%; adjusted hazard ratio, 2.11 [95% CI, 1.51-2.93]; P<0.001). A bovine arch anatomy is associated with a significantly higher risk of periprocedural and long-term stroke after TAVR.

Cerebral Embolic Protection in Transcatheter Aortic Valve Implantation Using the Sentinel Cerebral Protection System: A Systematic Review and Meta-Analysis.

Transcatheter aortic valve implantation (TAVI) plays a vital role in patients with symptomatic aortic stenosis. Despite the mortality benefit of TAVI, embolic stroke remains a feared complication. As a result, transcatheter cerebral embolic protection (TCEP) devices have been developed to reduce this risk. Given the ongoing debate of TCEP in TAVI, we performed a systematic review and meta-analysis of all randomized controlled trials to date to identify outcomes of periprocedural stroke using the Sentinel™ cerebral protection system (CPS). MEDLINE, Cochrane, and Scopus databases were utilized from inception until 12/2023. PRISMA criteria was utilized. Keywords included "cerebral embolic protection", "sentinel cerebral protection system", "transcatheter aortic valve implantation", and "transcatheter aortic valve replacement". Primary outcome was periprocedural stroke. Secondary outcomes included periprocedural disabling and non-disabling stroke, all-cause mortality, transient ischemic attack, delirium, acute kidney injury, vascular complications, bleeding, and pacemaker implantation. Risk ratios (RR) were measured via Mantel-Haenszel method with fixed analysis. Heterogeneity was assessed via chi-squared and Higgin's I2 test. Four trials with 3528 patients were assessed. SAPIEN 3 was the most common bioprosthetic valve used. The average age was 79.4years with 41.9% of the sample size being females. The most prevalent comorbidities were hypertension, diabetes mellitus, and coronary artery disease. There was no difference in periprocedural stroke in patients who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.75, P = 0.12). Periprocedural disabling strokes were less likely in those who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.41, P = 0.02) with a number needed to treat (NNT) of 123. All other outcomes did not reach statistical significance. In our analysis, there was no difference between TAVI with the Sentinel™ CPS compared to TAVI without TCEP in regard to risk of periprocedural stroke; however, it was associated with a decreased risk of periprocedural disabling stroke.

Similar 30 Day Clinical Outcomes After Carotid Artery Stenting By Different Medical Specialities: Analysis From a Large, Multicentre, European Roadsaver Study

Objective: Carotid artery disease treatment options include optimal medical therapy, surgical carotid endarterectomy (CEA), and endovascular carotid artery stenting (CAS). Clinical trials from the past two decades, comparing CEA with CAS reveal higher periprocedural (up to 30 days) risk of stroke or death with CAS. The higher risk is primarily noted in symptomatic patients (> 70 years old), while in younger and/or asymptomatic patients CEA and CAS outcomes are more comparable.1 Contemporary CAS is carried out by operators of different specialties, including angiologists, (neuro)radiologists, cardiologists, and vascular surgeons, the last of which are slightly underrepresented in the endovascular practice relative to other specialties. Newer generation dual layer micromesh stents (DLMS), were specifically designed to further decrease the CAS related periprocedural cerebral embolisation risk. Their short and long term safety and efficacy is supported by a large body of clinical evidence,2–5 but more studies in broader, unselected, patient populations are needed.

101 30-Day Outcomes of Resolute Onyx Stent for Symptomatic Intracranial Stenosis: A Multicenter Propensity-Score Matched Comparison With SAMMPRIS Trial

Symptomatic intracranial atherosclerotic disease (sICAD) is estimated to cause over 10% of strokes annually in the US alone. Previous investigations employing stenting, most notably SAMMPRIS trial, have produced unfavorable results in regards to both periprocedural complications and risk of recurrent stroke. However, newer generation balloon-mounted drug-eluting stents (BM-DES) have been hypothesized to harbor several technical advantages that may confer improvements in these critical metrics. Prospectively maintained databases from eight comprehensive stroke centers were reviewed to identify adult patients undergoing RO-ZES for the treatment of sICAD between January,2019 and December,2021. Only patients that presented with either recurrent stroke or TIA, intracranial stenosis 70-99%, with at least one stroke on best medical management were included. The primary outcome was 30-days composite of stroke, ICH, and/or mortality. A propensity-score matched analyses was performed comparing the results of RO-ZES to the intervention arm of SAMMPRIS. A total of 132 patients met the inclusion criteria for analysis (mean age:64.2 years). Mean severity of stenosis (±SD) was 81.4% (±11.4%). Four (3.03%) stroke and/or deaths were reported within 30 days in RO-ZES group. A propensity-score matched analysis based on age, HLD, HTN, DMII, and smoking demonstrated a statistically significant decreased risk of 30-day stroke and/or death rate in RO-ZES in comparison to SAMMPRIS (2.6% vs. 15.6%, respectively; OR 6.88, 95% CI 1.92-37.54, p < 0.001). Patients treated with RO-ZES had a decreased rate of 30-day major complications in comparison to SAMMPRIS. Further large-scale prospective studies are warranted to evaluate the safety and efficacy of RO-ZES for the treatment of sICAD.

Carotid Endarterectomy for Symptomatic Carotid Stenosis: Differences in Patient Profile in a Low-Middle-Income Country

Introduction: Carotid endarterectomy (CEA) is the standard treatment for patients with symptomatic carotid stenosis. Data from low- and middle-income countries are sparse on CEA and its outcomes. We aimed to describe the profile of our patients and factors associated with periprocedural cerebral ischemic events in patients with symptomatic carotid stenosis who underwent CEA in our institute. Methods: Retrospective review of patients with symptomatic carotid stenosis (50–99%) who underwent CEA between January 2011 and December 2021 was done. Clinical and imaging parameters and their influence on periprocedural cerebral ischemic events were analyzed. Results: Of the 319 patients (77% males) with a mean age of 64 years (SD±8.6), 207 (65%) presented only after a stroke. Majority (85%) had high-grade stenosis (≥70%) of the symptomatic carotid. The mean time to CEA was 50 days (SD±36); however, only 26 patients (8.2%) underwent surgery within 2 weeks. Minor strokes and TIA occurred in 2.2%, while major strokes and death occurred in 4.1% patients. None of the clinical or imaging parameters predicted the periprocedural cerebral ischemic events. The presence of co-existing significant (≥50%) tandem intracranial atherosclerosis (n = 77, 24%) or contralateral occlusion (n = 24, 7.5%) did not influence the periprocedural stroke risk. Conclusion: There is a delay in patients undergoing CEA for symptomatic carotid stenosis. Majority have high-grade stenosis and present late only after a stroke reflecting a lack of awareness. CEA can be performed safely even in patients with significant intracranial tandem stenosis and contralateral carotid occlusion.

Rate of periprocedural stroke in diagnostic cerebral angiograms comparing transradial versus transfemoral access.

Transradial access for neurointerventional procedures has increased in popularity over the past few years due to data from extrapolated interventional cardiology studies, patient preference, and early reports of feasibility using this approach. Our aim was to evaluate the incidence of periprocedural stroke in patients undergoing transradial versus transfemoral access for diagnostic cerebral angiograms. We retrospectively reviewed our neurointerventional database and identified all patients who underwent a diagnostic angiogram between May 2019 and July 2021. Patients were further divided into transradial versus transfemoral access. In patients with postprocedural stroke, symptoms and National Institute of Health Stroke Scale score were recorded. Pertinent laboratory values and procedural data was reviewed, including COVID status, platelet count, International normalized ratio (INR), Glomerular filtration rate (GFR), vessels catheterized, amount of contrast used, and fluoroscopy time. Imaging work-up for stroke symptoms was reviewed, if available. Thousand two-hundred thirty eight diagnostic cerebral angiograms with 656 patients (53%) undergoing transradial access. Stroke symptoms after angiogram were only observed in the transradial group (5 patients; 0.4% total and 0.8% among radial access cases, respectively). Symptoms included word finding difficulty, paresthesia, or weakness. Three patients underwent cross-sectional imaging, computed tomography was negative in all three patients. Magnetic resonance imaging showed small, scattered infarcts in two patients. All symptoms resolved without additional hospitalization. In our experience, using transradial access for diagnostic cerebral angiograms was associated with a low but not negligible incidence of periprocedural strokes. Patient anatomy should be evaluated prior to selection of vascular access. Patients should be made aware of a slightly higher periprocedural stroke risk with transradial access.

Periprocedural P2Y12 inhibitors improve perioperative outcomes after carotid stenting by primarily decreasing strokes

ObjectiveThe continuation of antiplatelet agents in the periprocedural period around carotid stenting (CAS) procedures is felt to be mandatory to minimize the risk of periprocedural stroke. However, the optimal antiplatelet regimen is unclear, with some advocating dual antiplatelet therapy, and others supporting the use of P2Y12 inhibitors alone. The objective of this study was to evaluate the periprocedural effect of P2Y12 inhibitors for CAS. MethodsThe Vascular Quality Initiative was used from years 2007 to 2020. All transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) procedures were included. Patients were stratified based on perioperative use of P2Y12 inhibitors as well as symptomatic status. Primary end points were perioperative neurological events (strokes and transient ischemic attacks). Secondary end points were mortality and myocardial infarction. ResultsA total of 31,036 CAS procedures were included for analysis, with 49.8% TCAR and 50.2% TF-CAS cases; 63.8% of patients were male and 82.3% of patients were on a P2Y12 inhibitor. P2Y12 inhibitor use was more common in males, asymptomatic patients, those older than 70 years, and concurrent statin use. P2Y12 inhibitors were more likely to be used in TCAR cases than in TF-CAS cases (87.3% vs 76.8%; P < .001). The rate of periprocedural neurological events in the whole cohort was 2.6%. Patients on P2Y12 inhibitors were significantly less likely to experience a periprocedural neurological event (2.3% vs 3.9%; P < .001) and mortality (0.6% vs 2.1%; P < .001) than those who were not on a P2Y12 inhibitor. There was no effect on the rates of myocardial infarction. On multivariate analysis, both symptomatic and asymptomatic patients on P2Y12 inhibitors were significantly less likely to develop perioperative neurological events. Additionally, the use of P2Y12 inhibitors demonstrated an independent significant effect in reducing of the rate of perioperative stroke (odds ratio, 0.29; 95% confidence interval, 0.25-0.33). Finally, additional analysis of the types of P2Y12 inhibitors used revealed that all seemed to be equally effective in decreasing the periprocedural neurological event rate. ConclusionsThe use of perioperative P2Y12 inhibitors seems to markedly decrease the perioperative neurological event rate with TCAR and TF-CAS in both symptomatic and asymptomatic patients and should be strongly considered. Patients with contraindications to P2Y12 inhibitors may not be appropriate candidates for any CAS procedure. Additionally, alternative types of P2Y12 inhibitors seem to be equally effective as clopidogrel. Finally, an analysis of the Vascular Quality Initiative demonstrates that, even for TCAR cases, only 87.3% of patients seem to be on P2Y12 inhibitors in the periprocedural period, leaving room for significant improvement.

Can carotid angioplasty stenting be better than endarterectomy or best medical treatment for patients with carotid stenosis?

Abstract Background Carotid stenosis is responsible for a considerable amount of strokes and related deaths. Carotid angioplasty stenting (CAS), endarterectomy (CEA) and best medical treatment (BMT) are important in preventing major cardiovascular (CV) events. Methods We conducted a systematic review and meta-analysis, with randomized controlled trials (RCT), to compare CAS with CEA and BMT regarding the short and long-term major periprocedural and follow-up CV events (stroke, myocardial infarction, and death) in symptomatic and asymptomatic carotid stenosis. We searched for RCT published from 2008 to 2021 in databases such as Pubmed/MEDLINE, B-On, Embase, Clinical Trials from U.S. National Library of Medicine and International Clinical Trials Registry Platform, between July of 2018 and January of 2019, and in October of 2021. Results Nine RCT were included, with a total of 9162 participants for CAS versus (vs) CEA, and 513 participants for CAS vs TMO. Compared with CEA, CAS is associated with periprocedural stroke and death in symptomatic patients (HR=1.65, 95% CI: 1.29–2.11, p=0.05, I2=62%), due to higher stroke events than deaths. That association does not occur in asymptomatic patients in which CAS is not associated with periprocedural stroke or death (CAS=8.55%, CEA=7.05%, p=0.09). During follow-up there were no significant differences between CAS and CEA in symptomatic patients regarding stroke (HR=1.51, 95% CI: 1.23–1.84, p=0.57, I2=0%) and death (HR=1.10, 95% CI: 0.93–1.30, p=0.69, I2=0%). Periprocedural myocardial infarction (MI) incidence is higher in CEA (CAS=1.1%; CEA=2.3%; p=0.03), without influence of symptomatic status. CAS is not inferior to CEA, in both symptomatic and asymptomatic patients with high surgery risk, as for periprocedural and one year CV major events (CAS=12.2%, CEA=20.1%, absolute difference = −7.9, 95% CI: −16.4–0.7, p=0.004). BMT had no significant findings vs CAS in asymptomatic patients (HR=3.5, 95% CI: 0.42–29.11, p=0.246). Conclusion CAS is not inferior to CEA as for the periprocedural and one-year major CV events in patients with normal surgery risk. However, there is a higher risk of periprocedural stroke in CAS for symptomatic patients, and of periprocedural MI in CEA with no influence of symptomatic status. CAS seams to prevent middle and long-term ipsilateral stroke in symptomatic patients. BMT has yet to prove not to be inferior to CAS in asymptomatic patients. Funding Acknowledgement Type of funding sources: None.

Thoracic Endovascular Aortic Repair with Supra-Aortic Trunk Revascularization is Associated with Increased Risk of Periprocedural Ischemic Stroke

Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study is to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR. The Vascular Quality Initiative registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysms. Our primary outcomes were any stroke or death at 30 days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable Poisson regression. Among 3,072 patients with degenerative aneurysms (197 [6.4%] arch versus 2,875 [93.6%] descending) treated with elective TEVAR, the median age was 73 years (interquartile range 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (52.9%), left carotid (20.7%), left vertebrobasilar (11.5%), right carotid (9.2%), and right vertebrobasilar (5.7%). Although mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysm versus descending aneurysms (7.1% arch versus 2.9% descending, P=0.001). Factors that were associated with ischemic stroke after TEVAR included age (>79years, relative risk [RR] 1.79, 95% confidence interval [CI] 1.08-2.98 vs. <79years), dependent functional status (RR 1.73, 95% CI 1.07-2.78), procedural time (RR 1.25, 95% CI 1.15-1.36), and endovascular intervention for supra-aortic trunk revascularization (RR 2.66, 95% CI 1.06-6.70 versus no intervention). Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increasing risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization.

Aortic Valve Calcium Score Is Associated With Acute Stroke in Transcatheter Aortic Valve Replacement Patients.

BackgroundTranscatheter aortic valve replacement (TAVR) is the treatment of choice for patients with severe aortic stenosis who are at a moderate or higher surgical risk. Stroke is a recognised and serious complication of TAVR, and it is important to identify patients at higher stroke risk. This study aims to discover if aortic valve calcium score calculated from pre-TAVR computed tomography is associated with acute stroke in TAVR patients.MethodsWe conducted a retrospective, observational cohort study of 433 consecutive patients undergoing TAVR between January 2017 and December 2019 at the Hammersmith Hospital.ResultsThis cohort had a median age of 83 years (interquartile range, 78-87), and 52.7% were male. Fifty-two patients (12.0%) had a history of previous stroke or transient ischemic attack. Median aortic valve calcium score was 2145 (interquartile range, 1427-3247) Agatston units. Twenty-two patients had a stroke up to the time of discharge (5.1%). In a logistic regression model, aortic valve calcium score was significantly associated with acute stroke (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.01-1.53; P = .02). Acute stroke was also significantly associated with peripheral arterial disease (OR, 4.32; 95% CI, 1.65-10.65; P = .0018) and a longer procedure time (OR, 1.01; 95% CI, 1.00-1.02; P = .0006).ConclusionsAortic valve calcium score from pre-TAVR computed tomography is an independent risk factor for acute stroke in the TAVR population. This is an additional clinical value of the pre-TAVR aortic valve calcium score and should be considered when discussing periprocedural stroke risk.

Important recommendations of the German-Austrian S3 guidelines on management of extracranial carotid artery stenosis

Lesions of the extracranial carotid artery are the cause of 10-15 % of all cases of cerebral ischemia. The aims of the updated S3 guidelines are evidence-based and consensus-based recommendations for action on comprehensive care of patients with extracranial carotid stenosis in Germany and Austria. A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews were carried out. Consensus answers to 37 key questions with evidence-based recommendations. The prevalence of extracranial carotid stenosis is approximately 4% and increases after the age of 65 years. The most important examination method is duplex sonography. Randomized controlled studies (RCT) have shown that carotid endarterectomy (CEA) of an asymptomatic 60-99% carotid artery stenosis reduces the absolute risk of stroke (absolute risk reduction, ARR) within 5 years in comparison to drug treatment alone by 4.1%. Due to an improved pharmaceutical prevention of arteriosclerosis, the S3 guidelines recommend a prophylactic CEA of a 60-99% stenosis only for patients without an increased surgical risk. Additionally, one or more clinical or imaging results should be present, which indicate an increased risk of carotid-related stroke in the follow-up. For medium-grade (50-69 %) and high-grade (70-99 %) symptomatic stenoses the ARRs after 5 years are 4.6% and 15.6%, respectively. Systematic reviews of RCTs have shown that CEA is associated with a ca. 50% lower periprocedural risk of stroke compared to carotid artery stenting (CAS). There are no differences in the long-term course. The CEA is recommended for high-grade asymptomatic, medium-grade and high-grade symptomatic carotid stenosis as a standard procedure, alternatively CAS can be considered. For both procedures the periprocedural stroke rate/mortality during hospitalization should be a maximum of 2% (asymptomatic stenosis) or 4% (symptomatic stenosis). Both CEA and CAS necessitate a critical evaluation of the indications and strict quality criteria. Future studies should evaluate even better selection criteria for an individual, optimal, conservative, operative or endovascular treatment.

Periprocedural P2Y12 Inhibitors Improve Perioperative Outcomes After Carotid Stenting by Primarily Decreasing Strokes

The continuation of antiplatelet agents in the periprocedural period around carotid stenting (transfemoral carotid artery stenting [TF-CAS] and transcarotid artery revascularization [TCAR]) procedures is believed to be mandatory to minimize the risk of periprocedural stroke.

TEVAR With Supra-Aortic Trunk Revascularization Is Associated With Increased Risk Of Periprocedural Ischemic Stroke

OBJECTIVE Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study was to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR. METHOD The Vascular Quality Initiative (VQI) registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysm. Our primary outcomes were any stroke or death at 30-days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable logistic regression. RESULT Among 3072 patients with degenerative aneurysms (197 [6.4%] arch vs. 2875 [93.6%] descending) treated with elective TEVAR, the median age was 73 (IQR 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (39.0%), left carotid (15.3%), left vertebrobasilar (8.5%), right carotid (6.8%), and right vertebrobasilar (4.2%). While mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysms versus descending aneurysms (7.1% arch vs. 2.9% descending, p=0.001). Factors that were associated with ischemic stroke after TEVAR included age (RR 1.06, 95% CI 1.03-1.09), operative time (RR 1.23, 95% CI 1.12-1.34), and endovascular intervention for supra-aortic trunk revascularization (RR 2.86, 95% CI 1.16-7.09 vs. no intervention). CONCLUSION Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increased risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization. Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study was to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR. The Vascular Quality Initiative (VQI) registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysm. Our primary outcomes were any stroke or death at 30-days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable logistic regression. Among 3072 patients with degenerative aneurysms (197 [6.4%] arch vs. 2875 [93.6%] descending) treated with elective TEVAR, the median age was 73 (IQR 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (39.0%), left carotid (15.3%), left vertebrobasilar (8.5%), right carotid (6.8%), and right vertebrobasilar (4.2%). While mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysms versus descending aneurysms (7.1% arch vs. 2.9% descending, p=0.001). Factors that were associated with ischemic stroke after TEVAR included age (RR 1.06, 95% CI 1.03-1.09), operative time (RR 1.23, 95% CI 1.12-1.34), and endovascular intervention for supra-aortic trunk revascularization (RR 2.86, 95% CI 1.16-7.09 vs. no intervention). Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increased risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization.

2021 Korean Heart Rhythm Society Guidelines for Catheter or Surgical Ablation of Atrial Fibrillation

Rhythm control therapy is used in atrial fibrillation (AF) management to improve AF-related symptoms along with rate control. AF catheter ablation is effective in maintaining sinus rhythm and has an acceptable complication rate. Compared with antiarrhythmic drugs, AF catheter ablation is superior with respect to arrhythmia-free survival and improvement in the quality of life. Therefore, AF ablation is recommended for rhythm control after the failure of antiarrhythmic drugs and is sometimes considered a first-line therapy for AF patients. Radiofrequency and cryoballoon ablation show similar efficacy, with slightly different complication profiles. Surgery for AF is also an effective rhythm control therapy and should be considered in patients undergoing cardiac surgery or in those with failed catheter ablation. For patients undergoing AF catheter ablation, performing ablation under uninterrupted warfarin or non-vitamin K oral anticoagulant treatment is recommended for periprocedural stroke risk management. Here, we review existing data and discuss the general principles of AF catheter and surgical ablation in patients with AF.

Carotid Duplex Poorly Predicts Stroke Risk During Transcatheter Aortic Valve Replacement

Patients undergoing surgical aortic valve replacement, in isolation or with concomitant coronary artery bypass grafting, have historically been screened for carotid artery disease prior to surgery. Over the past decade, transcatheter aortic valve replacement (TAVR) has incrementally become the predominant technique for the treatment of severe aortic stenosis. The relationship between internal carotid artery stenosis (ICAS) and risk of periprocedural stroke in the TAVR population is uncertain. We sought to evaluate our institution's outcomes with the TAVR procedure and the association with preoperative carotid duplex scan (CDS) results. A retrospective review of a single institution TAVR registry over a 5-year period was performed. All patients with pre-operative carotid imaging were included. Outcomes included in-hospital, 30-day, and 1-year stroke and all-cause mortality rates. The diagnosis of post-operative stroke was based on neurological exam and confirmed by radiologic imaging. Standard statistical analysis was performed. A total of 436 patients met inclusion criteria. The prevalence of ICAS >50% was 18.3% and 70-99% stenosis was 4.8%. The in-hospital stroke and mortality rates were 2.3% and 1.2%, respectively. The cumulative 30-day and 1- year stroke rates were 3.7% and 6%, respectively. All were ischemic in nature. Bilateral infarcts were identified in 46.2% of stroke patients and 11.5% had an ipsilateral ICAS >50%. A large majority of stroke patients (23, 88.5%) had an ipsilateral ICAS of <50%. Less than 0.5% of patients had ICAS >70% and subsequently had an ipsilateral stroke within 30 days of procedure. The preoperative CDS identified carotid lesions that met criteria for elective repair in only 4.8% of patients. Of these, 9.5% suffered a stroke in the first 30 days after surgery. Over 90% of patients who had a stroke had less than 70% stenosis present in either carotid artery and there was no correlation between degree of ICAS and risk of stroke during the follow-up period. Routine CDS prior to TAVR does not predict in-hospital or 30-day stroke. As TAVR programs evolve, expand, and proliferate across the country, routine preoperative CDS is unlikely to determine the need for pre-operative carotid revascularization or predict stroke risk.

Asymptomatic Stroke in the Setting of Percutaneous Non-Coronary Intervention Procedures.

Advancements in clinical management, pharmacological therapy and interventional procedures have strongly improved the survival rate for cardiovascular diseases (CVDs). Nevertheless, the patients affected by CVDs are more often elderly and present several comorbidities such as atrial fibrillation, valvular heart disease, heart failure, and chronic coronary syndrome. Standard treatments are frequently not available for “frail patients”, in particular due to high surgical risk or drug interaction. In the past decades, novel less-invasive procedures such as transcatheter aortic valve implantation (TAVI), MitraClip or left atrial appendage occlusion have been proposed to treat CVD patients who are not candidates for standard procedures. These procedures have been confirmed to be effective and safe compared to conventional surgery, and symptomatic thromboembolic stroke represents a rare complication. However, while the peri-procedural risk of symptomatic stroke is low, several studies highlight the presence of a high number of silent ischemic brain lesions occurring mainly in areas with a low clinical impact. The silent brain damage could cause neuropsychological deficits or worse, a preexisting dementia, suggesting the need to systematically evaluate the impact of these procedures on neurological function.

Predictors of the multiwire technique use in carotid artery stenting

ObjectivesThe multiwire technique (MWT) in carotid artery stenting (CAS), characterized by the use of more than one guidewire to support guiding catheter in patients with hostile neck anatomy, increases procedural time, enhancing the risk of periprocedural stroke. The aim of the present study was to identify which factors are predictors of the MWT use in CAS, in order to stratify patients with longer procedure at potential higher risk of periprocedural stroke. MethodsThe study retrospectively included patients who underwent CAS for stenotic plaque between January 2015 and December 2019. Exclusion criteria was incomplete clinical data. For each patients were registered clinical data, main aortic arch and supra-aortic vessel anatomical features, carotid plaque characteristics, and procedural details. The sample was divided in two group on the basis of the number of guides used during the stenting procedure: one guide (standard technique, ST) or more than one guidewire (MWT) to support the guiding catheter. Differences between groups were tested by Chi-square text or Fisher’s exact test and Mann-Whitney U test. Logistic regression analysis was used to identify predictors for the use of the MWT. The area under the ROC (AUC) curve was used to assess performance of the model to predict the use of the multiwire technique. ResultsThe final sample included 146 of the 204 (71%) patients who underwent CAS during the study period. The median age of the patients was 79 years (IQR 71–83 years) with 47/146 (32%) females. CAS was performed with MWT in 17/146 (12%) of the cases. MWT was used more likely in patients with aortic arch type II or III as compared to ST (71% vs 37%, P = 0.02) while plaques with heavy concentric calcifications were more frequent in ST as compared to MWT (38% vs 12%, P = 0.03). At multivariable analysis aortic arch type II or III (OR 5.08, 95% CI 1.48–17.93, P < 0.01), plaque stenosis > 79% (OR 4.13, 95% CI 1.03–16.61, P = 0.04), and plaque heavy concentric calcifications (OR 0.19, 95% CI 0.04–0.94, P = 0.04) were independent predictors of MWT use. The model showed an AUC of 0.827 (95% CI 0.756–0.884) for the prediction of the MWT use during CAS. ConclusionsAortic arch type II or III, carotid plaque with stenosis higher than 79% of the lumen or without heavy concentric calcifications were predictors for the use of the MWT during CAS. These features should be considered during planning of CAS as hallmark of vascular stiffness and therefore of higher procedure complexity.

Abstract 11872: Use of Dronedarone and Periprocedural Stroke Risk in Patients Undergoing Catheter Ablation for Atrial Fibrillation

Introduction: Dronedarone was introduced as a promising Amiodarone-analogue with a good safety profile and comparing efficacy. Because of a two-fold increase in all-cause death, stroke, myocardial infarction, and hospitalization in permanent AF, recommendations regarding the use of dronedarone therapy are limited. We aimed to evaluate the risk of periprocedural thromboembolic events (TE) in a group of patients who underwent catheter ablation for AF under on-going dronedarone therapy. Methods: We retrospectively studied 2254 AF cases who underwent catheter ablation between Jan 2011 and May 2017. A group of 145 cases out of the above cohort (mean age 65 yrs; male 54%; CHADSVASc &gt;2 on 51% of the cases; Persistent AF 21%) was under dronedarone at the time of catheter ablation. We compared the dronedarone (DG) vs non-dronedarone group (nDG) in terms of periprocedural TE, specifically transient ischemic attack and stroke. To assess the impact of other possible explanatory variables we performed a multivariate regression analysis with interaction terms. All patients were under optimal oral anticoagulation at the time of catheter ablation. Results: DG showed a significantly higher frequency of 2,06 % periprocedural TE compared to 0.5% in nDG (p=0,024). Significant predictors of TE in DG were found to be age (OR 2,7 p=0,036), persistent AF (OR 3,6 p=0,036), NYHA class at the time of catheter ablation (OR 2,35 p=0,006) and left ventricular systolic function (OR 1,37 p= 0,05).Intraprocedural median ACT (OR 1,04 p=0,024) and electrical cardioversion (OR 10,3 p= 0,003) were the two significant intraprocedural predictors for stroke among patients on Dronedarone at the time of pulmonary vein isolation. Not predictive for periprocedural stroke were the type of catheter ablation technique, gender, HASBLEED score and spontaneous echo contras in left atrium. There was a significantly higher risk of stroke in DG patients under Phenprocoumon vs the ones on NOACs (OR 6, p= 0,047). CHADSVasc &gt; 2 showed a trend in increasing the risk for stroke among DG patients (OR 3,1 p=0,07). Conclusions: Dronedarone therapy is associated with an increased risk for stroke in patients undergoing catheter ablation, with higher risk among the elderly, persistent AF, and heart failure patients.

Manual Thrombus Aspiration and its Procedural Stroke Risk in Myocardial Infarction.

BackgroundThe previous large‐scale randomized controlled trial showed that routine thrombus aspiration (TA) during percutaneous coronary intervention (PCI) was associated with an increased risk of stroke. However, real‐world clinical evidence is still limited.Methods and ResultsWe investigated the association between manual TA and stroke risk during primary PCI in the OACIS (Osaka Acute Coronary Insufficiency Study) database (N=12 093). The OACIS is a prospective, multicenter registry of myocardial infarction. The primary end point of the present study is stroke at 7 days. A total of 9147 patients who underwent primary PCI within 24 hours of hospitalization were finally analyzed (TA group, n=4448, versus non‐TA group, n=4699 patients). TA was independently associated with risk of stroke at 7 days (odds ratio [OR], 1.92 [95% CI, 1.19‒3.12]; P=0.008) in the simple logistic regression model, while the multilevel random effects logistic regression model with hospital treated as a random effect showed that manual TA was not associated with incremental risk of stroke at 7 days (OR, 0.91 [95% CI, 0.71‒1.16]; P=0.435). The 7‐day stroke risk of manual TA was significantly heterogeneous in different institutions (P for interaction=0.007).ConclusionsManual TA during primary PCI for patients with acute myocardial infarction was independently associated with the overall increased risk of periprocedural stroke. However, this result was substantially skewed because of institution specific risk variation, suggesting that the periprocedural stroke may be preventable by prudent PCI procedure or appropriate periprocedural management.RegistrationURL: https://upload.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000005464. Unique identifier: UMIN000004575.