Segmental Artery Occlusion Research Articles

Ultrasound-guided renal artery balloon catheter occluded hybrid partial nephrectomy (UBo-HPN) with branch renal artery occlusion: a single arm trial

BackgroundOne key focus of partial nephrectomy is preserving renal function. Segmental renal artery occlusion with microdissection at the renal hilum confines ischemia, effectively reducing warm ischemic injury. Ultrasound-Guided Renal Artery Balloon Catheter Occluded Hybrid Partial Nephrectomy (UBo-HPN) can achieve branch occlusion without the need for dissecting the renal hilum.ObjectiveTo investigate the feasibility and safety of UBo-HPN of branch renal artery occlusion in the treatment of localized renal tumors.Subject and methodsA prospective single-arm analysis involving 20 patients with renal localized tumors underwent robot assisted UBo-HPN with branch renal artery occlusion from August 2021 to July 2023, with an average follow-up of 12 months.ResultsAll patient was successfully operated on without conversion to conventional arterial clamping or radical nephrectomy. One case (5%) of minor complication occurred in the whole cohort, which was bruising around the puncture site. The mean total operative time was 95.8 min, with a mean operative time of 21.25 min for vascular intervention. The mean warm ischemia time was 20.35 min, and the median estimated blood loss was 50 ml. The median eGFR preservation percentage at postoperative 48 h, 30 days, and the latest follow-up were 87.52%, 91.47%, and 92.2%, respectively. After a median follow-up of 10.2 (2.3–19.2) months, no patients had radiological tumor recurrence or died from tumor-related causes.ConclusionsUBo-HPN with renal artery branch occlusion emerges as an efficient alternative to partial nephrectomy (PN), which achieved branch artery occlusion without dissecting the renal hilum. Long-term follow-up is expected for functional outcomes.

Endovascular occlusion of segmental arteries feeding the anterior spinal artery to stage endovascular thoracoabdominal aortic repair

ObjectiveMinimally invasive segmental artery coil embolization was introduced to prevent spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms. There is no consensus on whether the endovascular occlusion of segmental arteries feeding directly the anterior radiculomedullary artery and anterior spinal artery can be safely performed without causing spinal cord ischemia. Our aim was to investigate the feasibility and clinical impact of endovascular occlusion of segmental arteries supplying the anterior spinal artery during minimally invasive segmental artery coil embolization in patients with thoracoabdominal aortic aneurysms. MethodsBetween January 2018 and July 2020, 54 patients (36 male; mean age, 71.1 ± 9.3 years) underwent direct embolization of segmental arteries feeding the anterior radiculomedullary artery before endovascular repair of thoracoabdominal aortic aneurysms. End points included technical success of minimally invasive segmental artery coil embolization of segmental arteries, anterior radiculomedullary artery, neurological complications, and in-hospital mortality after minimally invasive segmental artery coil embolization and endovascular repair of thoracoabdominal aortic aneurysms. ResultsThe thoracoabdominal aortic aneurysm classification was type I (n = 8), type II (n = 24), type III (n = 11), and type IV (n = 11). During minimally invasive segmental artery coil embolization, 388 segmental arteries were occluded, each patient having 7.2 ± 3.1 coiled segmental arteries occluding 64.5% (25-100%) of open segmental arteries within the treated aortic segment. Altogether, 66 anterior radiculomedullary arteries were seen originating between Th8 and L3 levels from 85 (21.9%) segmental arteries. In 10 patients (18.5%), 2 large anterior radiculomedullary arteries were identified, and 1 patient (1.9%) showed 3 anterior radiculomedullary arteries on the spinal arteriography. No spinal cord ischemia or procedure-related complications occurred after minimally invasive segmental artery coil embolization. After 47.9 ± 39.4 days, all patients received endovascular repair of their thoracoabdominal aortic aneurysms. There was no in-hospital mortality. One male patient developed incomplete temporary spinal cord ischemia after endovascular repair. ConclusionsMinimally invasive segmental artery coil embolization of segmental arteries feeding the anterior spinal artery in patients with thoracoabdominal aortic aneurysms to prevent spinal cord ischemia after endovascular repair is feasible and clinically safe.

Association between clinical and sonographic patterns of major peripheral arterial occlusion among patients presenting with lower limb dry gangrene at a single center in Western Uganda

Abstract Background Dry gangrene occurs due to a reduced blood supply in body parts, resulting in gradual necrosis. It is among the leading indications for lower limb amputation; however, in situations where timely access of accurate diagnostic and revascularization services are limited, irrational amputations are performed based on mere physical assessment of a specific occluded major arterial segment, consequently preceded with gangrene recurrence on the same limb stump due to physical examination inaccuracies. Objectives We assessed the lower limb dry gangrene patterns and analyzed arterial Doppler reports of these cases to determine the associations between dry gangrene patterns and specific occluded major lower limb arteries to elevate the degree of accuracy of physical assessments. Methods In this cross-sectional study, 36 patients with lower limb dry gangrene were consecutively enrolled. Dry gangrene patterns and Doppler ultrasound reports of the major arteries of the affected lower limbs were assessed. Data were entered in EPIDATA and exported to STATA version 15 for cleaning and analysis. Clinical and sonographic characteristics are summarized as median and frequencies. Odds ratios (ORs) were tabulated and reported relating the dry gangrene patterns and major arterial occlusion levels as a measure of associations; P value < 0.05 were considered statistically significant. Results Dry gangrenes demarcated on the toes (61.1%), toes–distal foot 27.8%, and toes–proximal foot and leg (11.1%). Doppler ultrasound revealed femoral arteries (38.9%), popliteal (66.7%), and infra-popliteal (88.9%–100%) arterial occlusions. Association between dry gangrenes demarcating toes–proximal foot and leg with femoral arterial occlusions (ORs: 6.2 and 3.2, respectively), whereas dry gangrene demarcating toes and toes–distal foot with popliteal arterial occlusions (OR, 1.6; P value, 0.05). Conclusion Dry gangrene demarcating the toes–proximal foot and leg has a significant association with femoral arterial occlusions, whereas demarcation at the toes and toes–distal foot are more associated with popliteal arterial occlusions.

Abstract 143: Tigertriever in the Treatment of Acute Ischemic Stroke with Underlying Intracranial Atherosclerotic Disease

Introduction The Tigertriever stentretriever provides operators the ability to manually regulate the radial expansion of the device. In vitro testing of the Tigertriever has demonstrated that it exerts a radial force twice as powerful as that exerted by self‐expanding stentretrievers. The enhanced radial force of the Tigertriever may improve the recanalization of patients with acute large vessel occlusion (LVO) due to underlying intracranial atherosclerosis (ICAD). We analyzed the TIGER trial dataset to determine the safety and effectiveness of Tigertriever in the recanalization of patients with underlying ICAD and acute ischemic stroke. Methods An independent imaging laboratory assessed the presence of ICAD. ICAD was present if at least ≥ one of the following features were observed: (1) angiographic evidence of taper‐shape occlusion, (2) presence of arterial calcific lesions, and/or (3) remnant stenosis > 70% after mechanical thrombectomy (MT). Vessel diameter changes were studied by measuring the occlusion site and the proximal parent vessel using the best projection of pre‐ and post‐thrombectomy DSA images. additionally, a retrospective analysis of revascularization rates during the first attempt was conducted. The first‐pass effect (FPE) was defined as the achievement of successful recanalization (mTICI 2b‐3) using only one pass of the Tigertriever device. Results A total of 160 patients from the TIGER trial were included in our study, with 32 (20%) patients having ICAD. An increase in the mean diameter of the vessel at the site of the occlusion was observed post‐thrombectomy (1.5 ± 0.73 mm vs 1.88 ± 0.67 mm, p < 0.01). The diameter in the proximal parent vessel did not change after thrombectomy (2.22 ± 0.68 mm vs 2.32 ± 0.64 mm; p = 0.34). There were no symptomatic hemorrhages. The FPE was documented in of 15 out of 32 (46.8%) patients. Conclusion The Tigertriever device is safe and effective in the revascularization of patients with LVO and underlying ICAD. The diameter of the occluded arterial segment with underlying ICAD increased after mechanical thrombectomy with Tigertriever. The FPE with the Tigertriever in this subpopulation of the TIGER trial was 46.8%.

Semi-automated mapping of occluded arterial segments in acute large vessel stroke from computed tomography angiography

Catheterisation of occluded artery is the most crucial step in the mechanical thrombectomy of large vessel occlusions. Being a blind procedure, potential major untoward events could be anticipated at this stage. In this study, we evaluated the feasibility of reconstruction of the occluded vascular segment from CT angiography, exploiting the attenuation difference between the clot and adjacent brain parenchyma. Twenty-five patients with large vessel occlusion who achieved TICI2B/3 recanalization were identified. The semi-automated reconstruction was done using an open-source 3D segmentation software by two observers. The generated arterial anatomy was categorized as congruent, if all the major arterial segments namely, internal carotid artery, M1 middle cerebral artery, bifurcation, and major divisions matched with post thrombectomy angiograms. The discrepancy of one or more than one arterial segment was classified as mild or total mismatch respectively. Congruent arterial mapping was possible in 88% and 92 % patients for observer 1 and observer 2 respectively, while mild mismatch was noted in two patients for both the observers. Mismatch mostly occurred in superior division for both observers(100% vs 66.6%). The interrater agreement was good (0.77) and the accuracy was not influenced by the length of the clot. The median time for reconstruction was 4 minutes for both the observers (p - 0.21). Delineation of the anatomy of the occluded major intracranial artery is possible and corresponds with the actual anatomy. It could be used as a guide during thrombectomy procedures.

First Femoropopliteal Bypass for a Critical Limb Ischemia

First Femoropopliteal Bypass for a Critical Limb Ischemia

Eversion endarterectomy of a segmental occlusion of internal carotid artery patent due to an aberrant ascending pharyngeal artery: A case report

Type II segmental internal carotid artery (ICA) occlusion has been described by Kniemeyer et al1 as total occlusion of the ICA at the carotid bifurcation with delayed orthograde filling through atypical collateral vessels of the proximal ICA. We present a rare case of segmental ICA occlusion with an aberrant ascending pharyngeal artery (APA) that maintains the patency of the distal ICA.

Efficacy and safety of carotid endarterectomy combined with endovascular therapy in hybrid operating room for patients with segmental atherosclerotic internal carotid artery occlusion

The current study aimed to investigate the efficacy and safety of carotid endarterectomy combined with endovascular therapy in hybrid operating room for patients with segmental atherosclerotic internal carotid artery occlusion, and share the experience of preoperative screening of patients suitable for vascular reconstruction. A total of 20 patients with internal carotid artery occlusion (ICAO) who were admitted to the Department of Neurosurgery, General Hospital of Tianjin Medical University from May 2018 to May 2020 were collected, and 15 patients met the inclusion criteria. All patients received hybrid surgery. The total success rate of recanalization was 14/15, and only 1 patient developed ICA re-occlusion at 1 year follow up.Therefore, carotid endarterectomy combined with endovascular treatment in hybrid operating room was an alternative treatment for patients with segmental atherosclerotic internal carotid artery occlusion.

V10-02 ROBOTIC PARTIAL NEPHRECTOMY WITH REVERSIBLE SELECTIVE ARTERY ENDOLUMINAL BALLOON OCCLUSION ON A KIDNEY GRAFT

You have accessJournal of UrologyCME1 May 2022V10-02 ROBOTIC PARTIAL NEPHRECTOMY WITH REVERSIBLE SELECTIVE ARTERY ENDOLUMINAL BALLOON OCCLUSION ON A KIDNEY GRAFT Patrick-Julien Treacy, Severine Lagarde, Al Emadi Ibrahim, Thomas Prudhomme, Marine Lesourd, Rayan Atme, Matthieu Durand, Imad Bentellis, Michel Soulié, and Nicolas Doumerc Patrick-Julien TreacyPatrick-Julien Treacy More articles by this author , Severine LagardeSeverine Lagarde More articles by this author , Al Emadi IbrahimAl Emadi Ibrahim More articles by this author , Thomas PrudhommeThomas Prudhomme More articles by this author , Marine LesourdMarine Lesourd More articles by this author , Rayan AtmeRayan Atme More articles by this author , Matthieu DurandMatthieu Durand More articles by this author , Imad BentellisImad Bentellis More articles by this author , Michel SouliéMichel Soulié More articles by this author , and Nicolas DoumercNicolas Doumerc More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002623.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Small kidney tumors on renal grafts are accessible to partial nephrectomy surgery, but expose to clamping difficulties due to challenging access to graft vessels. Endoluminal balloons provide a reversible alternative to clamping of the graft artery. The objective of this video was to show the safety and efficiency of this technique for robot-assisted partial nephrectomy on kidney graft. METHODS: 69-year-old patient, transplanted in 2012, with extensive cardiovascular history. Discovery on follow-up ultrasound of a 2.5x2.3 cm tumor, confirmed by CT scan. Decision of robot-assisted partial nephrectomy after the multidisciplinary consultation meeting. An endoluminal balloon was placed in the segmental artery vascularizing the tumor after ponction of the femoral artery in interventional radiology. The patient was then installed in a supine position in the operating room for robotic-assisted partial nephrectomy, with trocar positioning similar to pelvic robotic surgery (assistant on the left side of the patient, two assistant trocars in the left iliac fossa and between the optical trocar and arm #1). RESULTS: The operative time in interventional radiology was 25 minutes, performed under local anesthesia. The operative time of the partial nephrectomy was 45 min, with a 10 min occlusion of the segmental artery. Blood loss was 200 cc. The postoperative period was uneventful, with the patient being discharged on day 2 after surgery. The serum creatinine level at discharge was 80 micromol/L, and the 3-month level was similar. Histopathologic analysis confirmed the malignant nature of the tumor, with clear cell renal cell carcinoma classified as pT1a Nx MO, nucleolar grade 3 (WHO 2018), with negative margins. 2 additional patients were performed using this technique, with similar results. CONCLUSIONS: Selective and reversible endoluminal balloon occlusion of segmental arteries appears to be a safe and effective alternative in arterial clamping for robotic-assisted partial nephrectomies on kidney grafts. A larger cohort will allow us to confirm our hypothesis. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e848 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patrick-Julien Treacy More articles by this author Severine Lagarde More articles by this author Al Emadi Ibrahim More articles by this author Thomas Prudhomme More articles by this author Marine Lesourd More articles by this author Rayan Atme More articles by this author Matthieu Durand More articles by this author Imad Bentellis More articles by this author Michel Soulié More articles by this author Nicolas Doumerc More articles by this author Expand All Advertisement PDF DownloadLoading ...

Distal transradial access for targeted spinal angiography and embolization.

Spinal catheter angiography is commonly performed in the evaluation and treatment of spinal vascular lesions. The typical approach to spinal angiography consists of access through the femoral artery with the use of suitably shaped catheters for selective catheterization of the spinal segmental vasculature. The purpose of our study was to evaluate the safety and feasibility of distal transradial access through the "anatomical snuffbox" for targeted spinal angiography, for the investigation and treatment of selected spinal lesions. A retrospective review of patients who underwent transradial spinal angiography and embolization was performed from August 2019 to January 2022. A total of eight patients were identified, who underwent targeted spinal angiography through distal transradial access. Outcome measures were documented in a tabular manner. Radial access was successful in all patients. Seven patients had vascular tumors of the spinal column and underwent tumor embolization followed by segmental artery occlusion prior to surgery. One patient had a spinal dural AV fistula that could not be embolized due to feeding vessel tortuosity and eventually went on to have a laminectomy. Mean fluoroscopy time was 31.4 min. There were no access site hemorrhagic complications. One patient experienced transient mild hand numbness during the period of hemostasis with the vascular compression device that resolved completely within 24 h. Distal transradial access is a feasible and safe option for targeted spinal angiography and treatment in selected patients.

Impact of distal aortic perfusion on 'segmental steal' depleting spinal cord blood flow-a quantitative experimental approach.

Aortic steal is an underestimated risk factor for intraoperative spinal cord ischaemia. A negative effect on spinal cord perfusion in thoraco-abdominal aneurysm repair has been suspected if blood drains away from the cord initiated by a reversal of the arterial pressure gradient. The amount of blood and pressure loss via back-bleeding of segmental arteries and the impact of distal aortic perfusion (DaP) have not been analysed yet. The aim of our study was to quantify 'segmental steal' in vivo during simulated thoraco-abdominal aneurysm repair and to determine the impact of DaP on steal and spinal cord perfusion. Ten juvenile pigs were put on cardiopulmonary bypass with DaP and visceral arteries were ligated. 'Segmental steal' was quantified by draining against gravity with/without DaP. Blood volume of 'segmental steal' was quantified and microspheres were injected for Post mortem spinal cord perfusion analysis. 'Segmental steal' was quantified with/without DaP-and with stopped DaP. Quantification revealed a significantly higher steal on cardiopulmonary bypass with DaP with a mean difference of 24(11) ml/min. In all spinal cord segments, blood flow was diminished during steal drainage on DaP, compared to 'no steal'. The least perfused region was the low thoracic to upper lumbar segment. 'Segmental steal' is a relevant threat to spinal cord perfusion-even with the utilization of DaP-diminishing spinal cord perfusion. The blood volume lost by back-bleeding of segmental arteries is not to be underestimated and occlusion of segmental arteries should be considered in thoraco-abdominal aneurysm repair.

Does segmental artery occlusion cause intravertebral cleft following osteoporotic vertebral fracture: a prospective magnetic resonance angiography study

BackgroundThe avascular necrosis (AVN) hypothesis of intravertebral cleft (IVC) formation in osteoporotic vertebral fracture (OVCF) has received increasing attention. The aim of this article is to detect whether the segmental artery occlusion causes the IVC following OVCF.MethodsBetween December 2019 and April 2020, 44 OVCF patients with 46 fracture levels were prospectively enrolled and the vertebral segmental arteries were evaluated by magnetic resonance angiography (MRA). The artery conditions were divided into patent, narrow and occluded. The lesion segmental occlusion rate (LSOR) and the total occlusion rate (TOR) were calculated. The association of segmental artery occlusion and IVC formation was assessed.ResultsLOSR was 15.34% and TOR was 15.12%. The segmental arteries of the unfractured vertebrae had a higher occlusion rate at thoracolumbar levels than at non-thoracolumbar levels. There was no significant difference between the IVC group and the non-IVC group in the fractured levels artery occlusion rate (20.24 ± 28.08 vs 9.78 ± 19.56, P = 0.156) or the total segmental arteries occlusion rate (13.83 ± 12.04 vs 11.57 ± 9.25, P = 0.476).ConclusionsIn patients with vertebral osteoporotic fracture, segmental artery occlusion is not associated with the development of intravertebral cleft.

Ultrastructural Study of Platelet Behavior and Interrelationship in Sprouting and Intussusceptive Angiogenesis during Arterial Intimal Thickening Formation.

Platelets in atherosclerosis, bypass stenosis, and restenosis have been extensively assessed. However, a sequential ultrastructural study of platelets in angiogenesis during the early phases of these lesions has received less attention. Our objective was the study of platelets in angiogenesis and vessel regression during intimal thickening (IT) formation, a precursor process of these occlusive vascular diseases. For this purpose, we used an experimental model of rat occluded arteries and procedures for ultrastructural observation. The results show (a) the absence of platelet adhesion in the de-endothelialized occluded arterial segment isolated from the circulation, (b) that intraarterial myriad platelets contributed from neovessels originated by sprouting angiogenesis from the periarterial microvasculature, (c) the association of platelets with blood components (fibrin, neutrophils, macrophages, and eosinophils) and non-polarized endothelial cells (ECs) forming aggregates (spheroids) in the arterial lumen, (d) the establishment of peg-and-socket junctions between platelets and polarized Ecs during intussusceptive angiogenesis originated from the EC aggregates, with the initial formation of IT, and (e) the aggregation of platelets in regressing neovessels (‘transitory paracrine organoid’) and IT increases. In conclusion, in sprouting and intussusceptive angiogenesis and vessel regression during IT formation, we contribute sequential ultrastructural findings on platelet behavior and relationships, which can be the basis for further studies using other procedures.

Overcoming severe calcified lower extremity artery in lower limb salvage operation by using the Fogarty catheter and vein graft.

With severe vascular calcifications, vascular clamp application and utilizing the vessel for free flap recipient vessel becomes impossible. These obstacles can be overcome with the Fogarty catheter and vein graft. When unclampable artery was encountered intraoperatively, a vein graft was used to make a clampable recipient site for six diabetic foot patients (ages from 42 to 80). The end of the Fogarty catheter was inserted into the proximal end of the vein graft and the transected calcified vessel in sequence, and the balloon of the catheter was used as an intraluminal tourniquet. The remaining end of the vein graft was connected to the distal vessel with a vascular clamp. Five short vein graft revascularization for segmental arterial occlusion, one long vein graft for recipient artery elongation was done (lengths from 2 to 13.8cm). Three delayed, and two immediate anterolateral thigh flaps (sizes from 15 to 150 cm2 ) were performed, and one patient received vein graft revascularization surgery only. Postoperative vascular sonography of all six patients showed well-maintained patency. Minor flap marginal disruption occurred at two patients but healed with conservative care. Postoperative follow-up was done for 1-18 months (average 7.17). Limb salvage was achieved for five patients and all five free flaps survived. However, for one patient, arterial restenosis at popliteal artery a month later lead to major amputation. Using a Fogarty catheter and a vein graft may obtain perfect hemostasis during micro-anastomosis and achieve successful microvascular reconstruction in patients with severely calcified vessels.

Spinal cord injury during selective cerebral perfusion and segmental artery occlusion: an experimental study.

Since selective cerebral perfusion (SCP) has been used in aortic arch surgical procedures, the core temperature during lower body circulatory arrest (LBCA) has been steadily rising. Simultaneously, the use of a frozen elephant trunk (FET) graft has been increasing. The safe period of LBCA in relation to spinal cord ischaemic tolerance in combination with segmental artery occlusion by the FET procedure has not been defined. Sixteen pigs were assigned to undergo 65 (n = 10) or 90 min (n = 6) of SCP at 28°C with LBCA in combination with occlusion of the 8 uppermost segmental arteries in the thoracic (Th) aorta (15-20 cm FET, Th8-level). The follow-up period consisted of a 6-h intensive period and a 5-day observation period. Near-infrared spectroscopy of the collateral network was used to determine spinal cord oxygenation. The neurological status of the patients was evaluated daily, and the brain and the spinal cord were harvested for a histopathological analysis. Five out of 6 pigs after 90 min and 1 out of 10 pigs after 65 min of LBCA died within 48 h of multiorgan failure. Of the survivors in the 65-min group, 6 out of 9 had paraparesis/paraplegia; the remaining 3 reached normal function. The lone survivor after 90 min of LBCA was paraplegic. Nadir near-infrared spectroscopy of the collateral network values at Th8 and Th10 were 34 (±5) and 39 (±4), and they were reached within 35 min of SCP in both groups. An extended FET graft with LBCA and SCP durations >65 min at 28°C results in a poor outcome.

Experimental near-infrared spectroscopy-guided minimally invasive segmental artery occlusion.

Minimally invasive staged segmental artery (SA) coil- and plug embolization is a new method for paraplegia prevention associated with extensive aortic procedures. Near-infrared spectroscopy of the paraspinal collateral network (cnNIRS) has emerged as a non-invasive method for spinal cord monitoring. The aim of this study was to evaluate cnNIRS to guide minimally invasive SA occlusion. In a chronic large animal experiment, 18 juvenile pigs underwent two-stage minimally invasive staged SA coil- and plug embolization for complete SA occlusion. Coil-embolization was performed either by SA main stem occlusion (characteristic of pig anatomy) or separately for the left- and right SA. Lumbar cnNIRS was recorded during and after the procedure. Neurological status was assessed up to 3 days after complete SA occlusion. Mean time from SA coil embolization to minimum cnNIRS values was 11 ± 5 min with an average decrease from 101 ± 2% to 78 ± 8% of baseline (difference: -23 ± 9, P < 0.001). Lumbar cnNIRS demonstrated significant differences between left and right when SAs were occluded separately in all cases (-7 ± 4%, 1 min after first SA occlusion; P = 0.001). Permanent paraplegia occurred in 2 (11%) and any kind of neurological deficit-temporary or permanent-in 7 animals (39%). Association between lumbar cnNIRS and neurological outcome after minimally invasive staged SA coil- and plug embolization suggests positive correlation (R = 0.5, P = 0.052). Lumbar cnNIRS independently reacts to unilateral SA occlusion. cnNIRS-guided SA occlusion is feasible and may become a useful adjunct facilitating adequate and complete vessel occlusion.

Inter-hospital transfer for mechanical thrombectomy within the supraregional stroke network NEVAS

BackgroundTelemedicine stroke networks are mandatory to provide inter-hospital transfer for mechanical thrombectomy (MT). However, studies on patient selection in daily practice are sparse.MethodsHere, we analyzed consecutive patients from 01/2014 to 12/2018 within the supraregional stroke network “Neurovascular Network of Southwest Bavaria” (NEVAS) in terms of diagnoses after consultation, inter-hospital transfer and predictors for performing MT. Degree of disability was rated by the modified Rankin Scale (mRS), good outcome was defined as mRS ≤ 2. Successful reperfusion was assumed when the modified thrombolysis in cerebral infarction (mTICI) was 2b-3.ResultsOf 5722 telemedicine consultations, in 14.1% inter-hospital transfer was performed, mostly because of large vessel occlusion (LVO) stroke. A total of n = 350 patients with LVO were shipped via NEVAS to our center for MT. While n = 52 recanalized spontaneously, MT-treatment was performed in n = 178 patients. MT-treated patients had more severe strokes according to the median National institute of health stroke scale (NIHSS) (16 vs. 13, p < 0.001), were more often treated with intravenous thrombolysis (64.5% vs. 51.7%, p = 0.026) and arrived significantly earlier in our center (184.5 versus 228.0 min, p < 0.001). Good outcome (27.5% vs. 30.8%, p = 0.35) and mortality (32.6% versus 23.5%, p = 0.79) were comparable in MT-treated versus no-MT-treated patients. In patients with middle cerebral artery occlusion in the M1 segment or carotid artery occlusion good outcome was twice as often in the MT-group (21.8% vs. 12.8%, p = 0.184). Independent predictors for performing MT were higher NIHSS (OR 1.096), higher ASPECTS (OR 1.28), and earlier time window (OR 0.99).ConclusionWithin a telemedicine network stroke care can successfully be organized as only a minority of patients has to be transferred. Our data provide clinical evidence that all MT-eligible patients should be shipped with the fastest transportation modality as possible.

Fast-track thrombolysis protocol for acute limb ischemia

ObjectiveCatheter-directed thrombolysis in the treatment of acute lower extremity arterial occlusions often requires several interventional sessions to generate successful outcomes. It is typically an expensive procedure, necessitating extended hospital length of stay (LOS) that may be associated with an increase in both local and systemic hemorrhagic complications. Five years ago, we created the fast-track thrombolysis protocol for arteries (FTTP-A) to deal with these concerns. The goal of our protocol is to re-establish patency during the first session of thrombolysis, thus decreasing costs and complications associated with prolonged periods of thrombolytic exposure. MethodsA retrospective study of 42 patients who were treated for acute limb ischemia at our institution by FTTP-A from January 2014 to February 2019 was performed. FTTP-A includes periadventitial lidocaine injection at the arterial puncture site under ultrasound guidance, contrast arteriography of the entire targeted segment, pharmacomechanical rheolytic thrombectomy of the occluded arterial segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and (if deemed necessary) placement of a stent in an area of significant (≥30%) stenosis that is refractory to balloon angioplasty and thrombolysis. After the stenosis or thrombus is cleared, patients are prescribed an oral anticoagulant agent. ResultsPrimary FTTP-A (50 total interventions) was performed in 42 patients. The median age of patients was 67.2 ± 12.2 years (range, 41-98 years), and 54.8% were male; 59.5% of the procedures were performed on the left lower extremity. Initial arterial access was obtained through the common femoral artery in 39 of 42 cases (92.9%); in the remaining 3 cases, it was obtained in a left bypass access site, a right femoral-popliteal graft, and a right femoral-femoral graft. The mean operative time was 148.9 ± 62.9 minutes (range, 83-313 minutes), and the mean volume of tissue plasminogen activator infused was 9.7 ± 4.0 mg (range, 2-20 mg). The median cost including medications and interventional tools was $4673.19 per procedure. The mean postoperative LOS was 3.1 ± 4.5 days (range, 1-25 days). Median postoperative LOS was 1 day. Mean postoperative follow-up was 27 ± 19.2 months (range, 0-62 months). Single-session FTTP-A was successful in 81% (n = 34/42) of patients; the remaining 8 patients (19%) required a single additional session. Of the 42 patients, 34 (81%) required arterial stenting. Periprocedural complications consisted of one patient with hematuria, which resolved, and one patient with thrombocytopenia, which resolved. No patients experienced rethrombosis within 30 days of FTTP-A. During the 5-year study period, there was no significant local or systemic hemorrhage, limb loss, or mortality related to this protocol. ConclusionsFTTP-A appears to be a safe, efficacious, and cost-effective procedure in the resolution of acute lower extremity arterial occlusions.

Arteriogenesis of the Spinal Cord-The Network Challenge.

Spinal cord ischemia (SCI) is a clinical complication following aortic repair that significantly impairs the quality and expectancy of life. Despite some strategies, like cerebrospinal fluid drainage, the occurrence of neurological symptoms, such as paraplegia and paraparesis, remains unpredictable. Beside the major blood supply through conduit arteries, a huge collateral network protects the central nervous system from ischemia—the paraspinous and the intraspinal compartment. The intraspinal arcades maintain perfusion pressure following a sudden inflow interruption, whereas the paraspinal system first needs to undergo arteriogenesis to ensure sufficient blood supply after an acute ischemic insult. The so-called steal phenomenon can even worsen the postoperative situation by causing the hypoperfusion of the spine when, shortly after thoracoabdominal aortic aneurysm (TAAA) surgery, muscles connected with the network divert blood and cause additional stress. Vessels are a conglomeration of different cell types involved in adapting to stress, like endothelial cells, smooth muscle cells, and pericytes. This adaption to stress is subdivided in three phases—initiation, growth, and the maturation phase. In fields of endovascular aortic aneurysm repair, pre-operative selective segmental artery occlusion may enable the development of a sufficient collateral network by stimulating collateral vessel growth, which, again, may prevent spinal cord ischemia. Among others, the major signaling pathways include the phosphoinositide 3 kinase (PI3K) pathway/the antiapoptotic kinase (AKT) pathway/the endothelial nitric oxide synthase (eNOS) pathway, the Erk1, the delta-like ligand (DII), the jagged (Jag)/NOTCH pathway, and the midkine regulatory cytokine signaling pathways.

Endovascular Treatment of TASC C- D Aorto-Iliac Occlusions: Analysis of Pre-Operative CT-Scan Can Predict Technical Failure

Introduction - While the outcomes of recanalization of TASC C-D aorto-iliac chronic total occlusions (CTO) are satisfying in high-volume centers, the risk of technical failure and the fear of iliac rupture especially in heavily calcified lesions limit the widespread use of this technique. To our knowledge, risks factor of technical failure or iliac rupture were poorly studied in the literature. We hypothesized that features of occlusion analyzable on pre-operative CT-scan could predict risks of technical failure or iliac rupture of endovascular treatment of TASC C-D aorto-iliac CTO. Methods - This is a retrospective study of a prospective cohort. All patients treated in our department by endovascular techniques for aTASC C-D aorto-iliac CTO between December 2009 and June 2016 were analyzed. Patients with no pre-operative CT-scan were excluded. We included 107 patients and 148 iliac arteries. All CT-scan were analyzed by 2 independent surgeons. Each side was analyzed independently. We evaluated the location of the occlusion and the degree of arterial calcifications. For this factor, patients were divided into 3 groups : the Black occlusion group (BO) defined by the presence of mild non protrusive calcifications or the complete absence of calcifications in all the aorta and iliac artery, the white occlusion group (WO) defined by moderate calcifications of more of 50 % of the arterial circumference but little or no protrusive in all the occlusion and the white protrusive occlusion group (WPO) defined by the presence of heavy endoluminal calcifications of more of 50 % of the arterial lumen in the occluded arterial segment. All patients had antegrade approach in case of failure of transfemoral approach. Primary endpoint was technical failure rate and secondary was iliac rupture rate. Wilcoxon, fisher exact test, univariate and multivariate regression model were performed. Results - CTO are located on the external iliac artery (EIA) in 37 cases, on the common iliac artery (CIA) in 41 cases, on both in 42 cases and on the aortic bifurcation in 14 cases. There were 66 iliac artery in the BO group, 45 in the WO group and 37 in the WPO group. Technical failure occurred in 8 patients that’s 11 iliac arteries. Per-operative iliac rupture occurred in 6 patients. In univariate analysis, only the location in the EIA is a significate risk factor of technical failure (OR = 9,93 and p = 0,0012). In multivariate analysis, this parameter is also an independant significate risk factor (OR = 15,26 and p = 0,0006). The presence of heavy calcifications is a further significate risk factor (OR = 13,88 and p = 0,0365). Rupture rate was comparable between the 3 groups (p = 0,881). Iliac rupture occur more for long lesions when both EIA and CIA were occluded but this is no significate (p = 0,282). Conclusion - The location of the CTO in the EIA is the major risk factor of technical failure of endovascular treatment for TASC C-D aorto-iliac CTO. The presence of heavy endoluminal calcifications is also a risk factor of technical failure. However, this parameter is not a risk factor of iliac rupture. The detailed analysis of pre-operative CT-scan can permit a better selection of patients for endovascular treatment of aorto-iliac CTO especially in low-volume centers. Referencesendovascular treatment, chronic total occlusion, aorto-iliac, technical failure, iliac rupture, predictors