Symptomatic Occlusion Research Articles

Outcomes of Nonagenarian Patients in Vascular Surgery Service in a Tertiary Institution.

With the world population growing and aging, nonagenarians have become a distinct patient cohort with specific characteristics that render the prediction of outcomes essential. We aimed to investigate the specific characteristics of this patient's cohort in a tertiary vascular center. Retrospective analysis was conducted for all consecutive patients 90 years and above referred or treated in the Department of Vascular Surgery between January 2017 and December 2022 for vascular pathologies. The main endpoint was to analyze the type of vascular services required for nonagenarians. Additional endpoints involved evaluation of treatment outcomes during the study period based on medical records. The analysis was patient-based. A total of 148 nonagenarians were included in the study. In all, 71 (48%) of the patients underwent surgery, whereas 77 (52%) had conservative treatment. Most of the patients were referred for peripheral arterial (PAD; 56, 37.8%) and aortic-related (39, 26.4%) diseases. Other pathologies encountered involved acute limb ischemia (ALI; 25, 16.9%), carotid diseases (12, 8.1%), renal/dialysis-related consultations (8, 5.4%), and referrals from other departments (12, 5.4%). Urgent interventions were performed in 27% of the cases. Indications for surgery included PAD Rutherford Stages IV, V, and VI; symptomatic and ruptured aortic aneurysms; ALI Rutherford Stages I, IIa, and IIb; symptomatic and near total occlusion asymptomatic carotid disease; and dialysis-related procedures for patients with chronic renal failure on regular hemodialysis. Perioperative complications were experienced in 22 patients (14.9%), the 30-day reintervention rate was 7.4%, and 30-day mortality was 4.7%. The overall length of hospital stay for operated patients was a median of 8 nights. The proportion of nonagenarians in the population is growing and so is their referral to vascular surgery. Satisfactory short-term treatment outcomes can be achieved in this highly selected cohort of patients. Thirty-day mortality is higher in patients undergoing urgent procedures. Follow-up mortality was higher in the operated nonagenarians as compared with those who were treated conservatively. Careful patient selection and thorough preparation are crucial to enhance clinical outcomes. Further research on therapy outcomes of nonagenarians will enable physicians to make better evidence-based approaches to individual patients and should be encouraged. The study highlights the growing need to manage vascular diseases in nonagenarians, emphasizing that age alone should not exclude patients from surgical interventions. By demonstrating acceptable short-term outcomes with careful patient selection, this research challenges the traditional bias against operating on the elderly. Clinicians should refine risk assessment and treatment plans, particularly when balancing surgical and conservative options. Comorbidities, rather than age, are key determinants of patient suitability, encouraging more individualized, evidence-based approaches in this expanding demographic.

A new angiographic scoring for grading the difficulty of recanalization for symptomatic non-acute middle cerebral artery occlusions.

Endovascular recanalization is a feasible option for treating symptomatic non-acute middle cerebral artery occlusion (MCAO) patients. Hence, we aimed to establish a new angiographic scoring to grade the recanalization difficulty of MCAO to determine the suitable patients for endovascular treatment. We retrospectively analyzed a total of 113 consecutive recurrent symptomatic non-acute MCAO patients who underwent endovascular recanalization from July 2015 to August 2021 in four Chinese comprehensive stroke centers. All patients were reappraised using a new angiographic scoring based on the stump morphology, the MCA occlusion length, MCA bend, and the distal vascular bed of MCAO. We used the final results to establish the patients' outcomes. The total successful recanalization and perioperative complication rates were 83.2% (94/113) and 15.9% (18/113), respectively. No deaths occurred within 30 days. Moreover, 96.9, 90, 87.5, 52.6, and 50% of the patients achieved recanalization with scores of 0, 1, 2, 3, and 4 (p < 0.001), respectively. However, the perioperative complication rate showed the opposite trend. (3.1% vs. 7.5% vs. 6.3% vs. 52.6% vs. 50%; p < 0.001). The median time of successful microwire crossing of the occlusion lesion (TMO) in the score 0 group was shorter than the other groups (2 min, 9 min, 8.5 min, 14 min, and 20 min; p < 0.001). When a score of 2 was used as the optimal cut-off point, the sensitivity and specificity were 86.2 and 63.2%, respectively. The new angiographic scoring can effectively predict the successful recanalization rate, perioperative complication rate, and TMO of endovascular recanalization for non-acute MCAO. It can also be used as an effective clinical evaluation tool to determine the suitable non-acute MCAO patients for recanalization, especially with a score ≤ 2.

Association between ASPECTS region of infarction and clinical outcome in non-acute large vessel occlusion ischaemic stroke after endovascular recanalisation

PurposeThis study retrospectively investigated whether infarction in specific Alberta Stroke Program Early CT Score (ASPECTS) regions is associated with clinical outcome in patients with symptomatic non-acute internal carotid or middle...

Perfusion deficit and vessel wall characteristics to predict recurrent ischemic events in medically treated patients with chronic symptomatic anterior circulation large vessel occlusion.

To investigate the association between perfusion deficit, vessel wall characteristics, and risk of recurrent ischemic events in medically treated patients with chronic symptomatic anterior circulation large vessel occlusion. We retrospectively reviewed chronic symptomatic patients due to anterior circulation large vessel occlusion in our center. All patients received multiparametric magnetic resonance imaging (including perfusion-weighted imaging and high-resolution vessel wall imaging) within 4 weeks to 3 months after symptom onset. The association between baseline clinical or imaging variables and recurrent ischemic events was assessed in bivariate models and multivariable logistic regression to identify independent predictors of recurrence. Among 71 enrolled patients, 21.1% (15/71) patients had recurrent ischemic events (nine ischemic strokes and six transient ischemic attacks) during a 2-year follow-up. In bivariate models, hypertension, occlusion with hyperintense signals, the presence of intraluminal thrombus, Tmax >4 s volume, Tmax >6 s volume, Tmax >8 s volume, and Tmax >10 s volume were associated with recurrence (all p < 0.05). In multivariate analysis, hypertension (p = 0.039, OR 10.057 (95% CI, 1.123-90.048)), higher deficit volume of Tmax >4 s (p = 0.011, OR 1.012 (95% CI, 1.003-1.021)) and occlusion with hyperintense signal (p = 0.030, OR 6.732 (95% CI, 1.200-37.772)) were still independent predictors of recurrent ischemic events. Besides hypertension history, higher deficit volume of Tmax >4 s and occlusion with hyperintense signal determined using multiparametric MRI are strongly associated with risk for recurrent ischemic events in medically treated patients with chronic symptomatic anterior circulation large vessel occlusion. Future studies are needed to determine the utility of revascularization strategies in such high-risk patients.

Potential of BMI as a screening indicator for extracranial-intracranial bypass surgery in patients with symptomatic artery occlusion: a post-hoc analysis of the CMOSS trial.

To investigate the association between BMI and the incidence of ischemic stroke in patients with symptomatic artery occlusion, and further to evaluate the utility of BMI as a screening tool for identifying candidates for extracranial-intracranial bypass surgery. The authors analyzed the relationship between BMI and the occurrence of ipsilateral ischemic stroke (IIS) among patients receiving only medical management in the Carotid or Middle cerebral artery Occlusion Surgery Study (CMOSS). Additionally, the authors compared the primary endpoint of CMOSS-stroke or death within 30 days, or IIS after 30 days up to 2 years-among patients with varying BMIs who underwent either surgery or medical treatment. Of the 165 patients who treated medically only, 16 (9.7%) suffered an IIS within 2 years. BMI was independently associated with the incidence of IIS (hazard ratio: 1.16 per kg/m 2 ; 95% CI: 1.06-1.27). The optimal BMI cutoff for predicting IIS was 24.5kg/m 2 . Patients with BMI ≥24.5kg/m 2 experienced a higher incidence of IIS compared to those with BMI <24.5kg/m 2 (17.4 vs. 0.0%, P <0.01). The incidence of the CMOSS primary endpoint was significantly different between the surgical and medical groups for patients with BMI ≥24.5kg/m 2 (5.3 vs. 19.8%, P <0.01) and those with BMI <24.5kg/m 2 (10.6 vs. 1.4%; P =0.02). Surgical intervention was independently associated with a reduced rate of the CMOSS primary endpoint in patients with BMI ≥24.5kg/m 2 . Data from the CMOSS trial indicate that patients with BMI ≥24.5kg/m 2 are at a higher risk of IIS when treated medically only and appear to derive greater benefit from bypass surgery compared to those with lower BMIs. Given the small sample size and the inherent limitations of retrospective analyses, further large-scale, prospective studies are necessary to confirm these findings.

Hybrid Surgery for symptomatic chronic internal carotid artery occlusion: a single-center experience.

Patients with symptomatic chronic internal carotid artery occlusion (ICAO) face a high risk of recurrent stroke despite receiving aggressive medical therapy. This study aimed to evaluate the effectiveness and safety of hybrid surgery in treating symptomatic chronic ICAO. This retrospective case series was conducted at a single center. From January 2019 to December 2022, patients with symptomatic chronic ICAO who underwent hybrid surgery were included. We collected baseline data, lesion characteristics, revascularization rates, perioperative complications, and follow-up outcomes. The study enrolled 27 patients, comprising 22 males and 5 females, with symptomatic chronic ICAO. The hybrid surgery achieved a technical success rate of 100% for revascularization (n = 27), with a perioperative complication rate of 14.8% (n = 4). Following a median follow-up of 6.0months (IQR, 4-10), 21 patients underwent a DSA or CT angiography reexamination, confirming a vascular patency rate of 90.5% (n = 19). One patient required surgery for severe in-stent restenosis, and another experienced asymptomatic occlusion. Clinical follow-ups were conducted for all 26 patients; no new strokes were reported in the qualifying artery territory, with 13 patients scoring 0, 12 scoring 1, and 1 scoring 2 on the mRS. Although hybrid surgery represent a promising option for treating chronic ICAO, they are also associated with a relatively high incidence of treatment-related complications. The application of composite surgery should be based on standardized technical guidelines and the careful selection of patients who are genuinely at high risk for recurrent strokes.

Use of intermediate cervical plexus block in carotid endarterectomy –an alternative to deep cervical plexus block: a case series

IntroductionCarotid endarterectomy is performed for patients with symptomatic carotid artery occlusions. Surgery can be performed under general and regional anesthesia. Traditionally, surgery is performed under deep cervical plexus block which is technically difficult to perform and can cause serious complications. This case series describes 5 cases in which an intermediate cervical plexus block was used in combination with a superficial cervical plexus block for Carotid endarterectomy surgery.MethodsFive patients who were classified as American Society of Anesthesiologists 2–3 were scheduled for Carotid endarterectomy due to symptoms and more than 70% occlusion of the carotid arteries. The procedures were carried out in the University Teaching Hospital- Peradeniya, Sri Lanka. All patients were given superficial cervical plexus block followed by intermediate cervical plexus block using 2% lignocaine and 0.5% plain bupivacaine.ResultsAdequate anesthesia was achieved in 4 patients, and local infiltration was necessary in 1 patient. Two patients developed hoarseness of the voice, which settled 2 h after surgery. Hemodynamic fluctuations were observed in all 5 patients. No serious complications were observed. All 5 patients had uneventful recoveries.DiscussionsRegional anesthesia for CEA is preferable in patients who are medically complicated to undergo anesthesia or in patients for whom cerebral monitoring is not available. Intermediate cervical plexus block is described for thyroid surgeries in literature, but not much details on its use for carotid surgeries. Deep cervical plexus blocks has few serious complications which is not there with the use of ICPB making it a good alternative for CEA surgeries .ConclusionsSuperficial cervical plexus block and intermediate cervical plexus block can be used effectively for providing anesthesia for patients undergoing Carotid endarterectomy. It is safe and easier to conduct than deep cervical plexus block and enables monitoring of cerebral function.

Effectiveness of computed tomography perfusion imaging in stroke management.

Current guidelines do not support the use of computed tomography perfusion (CTP) in stroke, except when identifying the penumbra during an extended treatment window. Therefore, this study aimed to define the yield of CTP in diagnosing a stroke diagnosis beyond the imaging of the penumbra in the hyperacute phase (0-6 h) and an extended time window (6-24 h). All consecutive patients with acute onset of symptoms within a 24-h window underwent CTP imaging. The diagnostic value of CTP was calculated against the clinical and radiological diagnoses of stroke. A positive CTP result was determined by the presence of either a core or penumbra on the RAPID summary. Clinical diagnoses corresponded to discharge diagnoses of stroke. A radiological diagnosis was established if early ischemic changes [Alberta Stroke Program Early CT Score (ASPECTS) <10] were observed on the baseline CT scan, acute infarction was confirmed on follow-up imaging, or symptomatic occlusion was evident on baseline CTA. Between November 2018 and November 2019, 585 consecutive patients with an acute neurological deficit underwent multimodal CT imaging. A total of 500 patients (85%) were included, where 274 (55%) were within the hyperacute phase, 153 (31%) had a radiological diagnosis of stroke, and 122 (24%) had a clinical diagnosis of stroke. CTP yielded positive results only in patients with a confirmed stroke (positive predictive value and specificity of 100%). When CTP results were negative, 43% of the cases turned out to stroke mimics. Patients with stroke mimics were younger (66 ± 17 vs. 73 ± 13) and had lower scores on the National Institutes of Health Stroke Scale [median 0; interquartile range (IQR) 0-2 vs. median 4; IQR 2-6] compared to patients with CTP-negative strokes. In our study, CTP consistently indicated brain ischemia; therefore, in stroke management, CTP is most beneficial when it yields a positive result. A positive CTP result should prompt adequate stroke management actions without any delay. Conversely, a negative CTP result necessitates the consideration of both stroke and non-stroke diagnoses.

Qualifying Event and Recurrence of Ischemic Stroke in Symptomatic Artery Occlusion: A Post Hoc Analysis of CMOSS.

The authors aimed to elucidate the relationship between latest ischemic event and the incidence of subsequent ischemic stroke in patients with symptomatic artery occlusion. We analyzed the association between qualifying event-the latest ischemic event (transient ischemic attack [TIA] or stroke)-and the incidence of ipsilateral ischemic stroke in patients with symptomatic artery occlusion treated with medical therapy alone in CMOSS (Carotid or Middle Cerebral Artery Occlusion Surgery Study). The incidence of CMOSS primary outcomes, including any stroke or death within 30 days after randomization or ipsilateral ischemic stroke between 30 days and 2 years, between the bypass surgical and medical groups, stratified by qualifying events, was also compared. Of the 165 patients treated with medical therapy alone, 75 had a TIA and 90 had a stroke as their qualifying event. The incidence of ipsilateral ischemic stroke did not significantly differ between patients with a TIA and those with a stroke as their qualifying event (13.3% versus 6.7%, P=0.17). In multivariate analysis, the qualifying event was not associated with the incidence of ipsilateral ischemic stroke. There were no significant differences in the CMOSS primary outcomes between the surgical and medical groups, regardless of the qualifying event being TIA (10.1% versus 12.2%, P=0.86) or stroke (6.7% versus 8.9%, P=0.55). Among patients with symptomatic artery occlusion and hemodynamic insufficiency, the risk of subsequent ipsilateral ischemic stroke does not appear to be lower in patients presenting with a TIA compared with those with a stroke. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01758614.

The use and abuse of survival analysis and Kaplan-Meier curves in surgical trials

BackgroundSurvival analysis based on Cox regression and Kaplan-Meier curves, initially devised for oncology trials, have frequently been used in other contexts where fundamental statistical assumptions (such as a constant hazard ratio) are not satisfied. This is almost always the case in trials that compare surgery with medical management. MethodsWe review a trial that compared extracranial-intracranial bypass surgery (EC-IC bypass) with medical management (MM) of patients with symptomatic occlusion of the carotid or middle cerebral artery, where it was claimed that surgery was of no benefit. We discuss a hypothetical study and review other neurovascular trials which have also used survival analysis to compare results. ResultsThe trial comparing EC-IC bypass and MM did not satisfy the fundamental proportional hazard assumption necessary for valid analyses. This was also the case for two prior EC-IC bypass trials, as well as for other landmark neurovascular studies, such as the trials comparing endarterectomy with MM for carotid stenoses, or for the trial that compared intervention and MM for unruptured brain arteriovenous malformations. While minor deviations may have little effect on large trials, it may be impossible to show the benefits of surgery when trial size is small and deviations large. ConclusionSurvival analyses are inappropriate in RCTs comparing surgery with conservative management, unless survival is calculated after the postoperative period. Alternative ways to compare final clinical outcomes, using for example a fixed follow-up period, should be planned for preventive surgical trials that compare intervention with conservative management.

Differences between Acute Embolic and Atherosclerotic Middle Cerebral Artery Occlusion in Multiphase Arterial Spin-labeling Imaging.

Arterial spin-labeling magnetic resonance imaging (ASL-MRI) is widely used for evaluating collateral development in patients with acute ischemic stroke (AIS). This study aimed to characterize the findings of multiphase ASL-MRI between embolic and atherosclerotic large vessel occlusion (LVO) to aid in the differential diagnosis. Among 982 patients with AIS, 44 who were diagnosed with acute, symptomatic, and unilateral occlusion of the horizontal segment of the middle cerebral artery (MCA) were selected and categorized into embolic stroke (ES) and atherosclerosis (AT) groups. Using ASL-MRI (postlabeling delay [PLD] of 1.5, 2.0, and 2.5 s) at admission, the ipsilateral to contralateral ratio (ICR) of the signal intensity and its time-course increasing rate (from PLD 1.5 to 2.0 and 2.5, ΔICR) were measured and compared between the two groups. The mean ICR was significantly higher in the AT group than in the ES group (AT vs. ES: 0.49 vs. 0.27 for ICR1.5, 0.73 vs. 0.32 for ICR2.0, and 0.92 vs. 0.37 for ICR2.5). The ΔICR of PLD 1.5-2.0 (ΔICR2.0) and 2.5 (ΔICR2.5) were also significantly higher in the AT group than in the ES group (AT vs. ES: 50.9% vs. 26.3% for ΔICR2.0, and 92.6% vs. 42.9% for ΔICR2.5). Receiver operating characteristic curves showed moderate-to-strong discriminative abilities of each ASL-MRI parameter in predicting MCA occlusion etiology. In conclusion, multiphase ASL-MRI parameters may aid in differentiating intracranial LVO etiology during the acute phase. Thus, it is applicable to AIS management.

Significance of atherosclerotic plaque location in recanalizing non-acute long-segment occlusion of the internal carotid artery

To investigate the significance of atherosclerotic plaque location in hybrid surgery comprising both endovascular recanalization approaches and carotid endarterectomy for symptomatic atherosclerotic non-acute long-segment occlusion of the internal carotid artery (ICA), 162 patients were enrolled, including 120 (74.1%) patients in the proximal plaque group and 42 (25.9%) in the distal plaque group. Surgical recanalization was performed in all patients, with successful recanalization in 119 (99.2%) patients in the proximal and 39 (92.9%) in the distal plaque group. The total successful recanalization rate was 97.5% (158/162) with a failure rate of 2.5% (4/162). Periprocedural complications occurred in 5 (4.2% or 5/120) patients in the proximal plaque group, including neck infection in two (1.7%), recurrent nerve injury in 1 (0.8%), and laryngeal edema in 2 (1.7%), and 2 (4.8%) in the distal plaque group, including femoral puncture infection in 2 (4.8%). No severe complications occurred in either group. Univariate analysis showed plaque location was a significant (P = 0.018) risk factor for successful recanalization, and multivariate analysis indicated that the plaque location remained a significant independent risk factor for recanalization success (P = 0.017). In follow-up 6–48 months after the recanalization surgery, reocclusion occurred in two (2.8%) patients in the proximal plaque group and 4 (13.3%) in the distal plaque group. In conclusion, although hybrid surgery achieves similar outcomes in patients with ICA occlusion caused by either proximal or distal atherosclerotic plaques, plaque location may be a significant risk factor for successful recanalization of symptomatic non-acute long-segment ICA occlusion.

Stenting for subclavian steal phenomenon to restore cerebral perfusion due to acute carotid occlusion following carotid endarterectomy: a case report

BackgroundPerioperative symptomatic carotid artery occlusion after carotid endarterectomy is a rare complication. In this study, we present a case of symptomatic acute carotid artery occlusion that occurred after carotid endarterectomy in a patient with coexistent subclavian artery steal phenomenon, which was successfully treated with subclavian artery stenting.Case presentationA 57-year-old East Asian female presented with stenosis in the left common carotid artery and left subclavian artery along with subclavian steal. The proximal segment of the left anterior cerebral artery was hypoplastic, and the posterior communicating arteries on both sides were well-developed. Left internal carotid artery stenosis progressed during the follow-up examination; therefore, left carotid endarterectomy was performed. On the following day, symptoms of cerebral perfusion deficiency appeared due to occlusion of the left carotid artery. The stenotic origin of the left common carotid artery and the suspected massive thrombus in the left carotid artery posed challenges to carotid revascularization. Therefore, left subclavian artery stenting for the subclavian steal phenomenon was determined to be the best option for restoring cerebral blood flow to the whole brain. Her symptoms improved after the procedure, and the postprocedural workup revealed improved cerebral blood flow.ConclusionSubclavian artery stenting is safe and may be helpful in patients with cerebral perfusion deficiency caused by intractable acute carotid occlusion coexisting with the subclavian steal phenomenon. Revascularization of asymptomatic subclavian artery stenosis is generally not recommended. However, cerebral circulatory insufficiency as a comorbidity may be worth considering.

Extracranial-intracranial (EC-IC) Bypass Versus Medical Therapy Alone in Patients with Symptomatic Artery Occlusion: A Systematic Review and Meta-analysis (P8-5.030)

Extracranial-intracranial (EC-IC) Bypass Versus Medical Therapy Alone in Patients with Symptomatic Artery Occlusion: A Systematic Review and Meta-analysis (P8-5.030)

The interpositional bypass with a parietal branch of superficial temporal artery graft for symptomatic atherosclerotic anterior cerebral artery stenosis or occlusion.

For nonmoyamoya patients with anterior cerebral artery (ACA) stenosis or occlusion, whether direct revascularization of the ACA territory can prevent stroke is still unclear. The objective of this study was to investigate the efficacy and safety of a parietal branch of superficial temporal artery-interposed superficial temporal artery-to-ACA bypass (PISAB) for preventing stroke in patients with symptomatic atherosclerotic ACA stenosis or occlusion (SAASO). We retrospectively analyzed the data from patients with SAASO who had undergone PISAB in our center between April 2016 and November 2021. The rates of patency, satisfaction (revascularization grades A and B) of bypass, perioperative complications, recurrence of ischemic stroke, changes in bypass flow, and improvements in cerebral blood perfusion were analyzed. A total of 19 SAASO patients were involved in this study. Sixteen out of 19 (84.2%) patients were free from any cerebral ischemic events after surgery. Only 3 patients (15.8%) had recurrent stroke postoperatively. Two (10.5%) surgery-related complications occurred, including hyperperfusion syndrome and minor stroke. No skin ischemic complications occurred. The average follow-up period was 50.6 ± 18.3 months. The flow rate of the bypass was significantly increased half a year after surgery (56.2 ± 8.0 mL/min vs. 44.3 ± 5.3 mL/min, p < 0.001). The ratio of ipsilateral/contralateral mean transit time in the superior frontal gyrus was decreased significantly after bypass (1.08 ± 0.07 vs. 1.23 ± 0.05, p < 0.001) and continued to decrease 6 months after surgery (1.05 ± 0.04 vs. 1.08 ± 0.07, p = 0.002). The patency rate of PISAB was 94.7% (18/19) 2 years after surgery. The satisfaction rate of bypass was 89.5% (17/19). The results of this study indicate that PISAB, as a safe superficial bypass, can effectively reduce the risk of stroke in SAASO patients. More precise conclusions will require randomized control studies.

Long-term outcomes after formation of a low-flow STA-MCA bypass for treatment of symptomatic occlusion of the internal carotid artery

Aim. To evaluate short‑ and long‑term effectiveness of low‑flow bypass between superficial temporal artery and M4 segment of middle cerebral artery (low‑flow STA‑MCA bypass) in patients with symptomatic occlusion of the internal carotid artery (ICA).Materials and methods. Between 2016 and 2019 at the Department of Neurosurgery of the N. V. Sklifosovsky Research Institute of Emergency Medicine, 54 patients who underwent low‑flow STA‑MCA bypass formation at the side of symptomatic ICA occlusion between 2013 and 2015 were examined. Symptomatic ICA occlusion was more common in men than in women (7:1 ratio). Patient age varied between 48 and 73 years (mean age was 62 years).During low‑flow STA‑MCA bypass formation surgery for symptomatic ICA occlusion, intraoperative flowmetry was used in 52 (96 %) patients, in 2 (4 %) patients this diagnostic method was impossible to perform due to technical difficulties. The main examination methods in the long term after cerebral revascularization were evaluation of neurological status dynamics per the National Institute of Health Stroke Scale (NIHSS); modified Rankin scale; Rivermead mobility index; computed tomography angiography of the extra‑intracranial arteries; ultrasound (US) examination of the STA‑MCA bypass for eval uation of linear and volumetric blood flow velocities; single‑photon emission computed tomography. The type and size of trephination were evaluated, and operative time was taken into account.The patients were divided into 3 groups: group 1 included patients with follow‑up period of 1–2 years after cerebral revascularization, group 2 – 3–4 years, group 3 – 5–6 years. All results were compared to preoperative, early, and longterm measurements.Results. In the long‑term postoperative period between 1 and 6 years after cerebral revascularization, 54 patients were examined. Computed tomography angiography and US showed functioning STA‑MCA bypass in 53 (98 %) patients. According to single‑photon emission computed tomography of the brain, regional cerebral blood flow in the longterm postoperative period varied between 28 and 40 mL / 100 g / min, median regional cerebral blood flow in the long‑term postoperative period was 38 mL / 100 g / min. Intraoperative flowmetry was performed in 52 (96 %) patients, median was 15.5 mL / min. US showed that linear blood flow velocity in the STA‑MCA bypass varied between 20 and 95 cm / s, median was 49 cm / s. Volumetric blood flow varied between 30 and 85 mL / min with median of 75 mL / min.Resection trephination was performed in 36 (67 %) patients, mean size of trephination hole was 3 cm3. In the study, operative time was measured: mean value was 212 min; no significant correlation between operative time and trephination size was observed.Improved neurological status was observed in all study groups. Per the NIHSS, in group 1 (1–2 years) improvement was observed in 59 % of patients, in group 2 (3–4 years) in 48 %, in group 3 (5–6 years) in 47 %. Per the modified Rankin scale, in group 1 improvement was observed in 36.4 % of patients, in group 2 – in 48 %, in group 3 – in 42.9 %. Per the Rivermead mobility index, in group 1 improvement was observed in 63.3 % patients, in group 2 – in 56 %; in group 3 – in 57.1 %. The best outcomes were observed in group 1 (63.3 %).Conclusion. Instrumental diagnostic methods and evaluation of neurological status showed positive dynamics both in the postoperative period and in long‑term period between 1 and 6 years after low‑flow STA‑MCA bypass formation. In the long term, repeat abnormalities of cerebral blood flow of ischemic type and repeat transient ischemic attacks were not observed. Correct selection of patients in the preoperative period and comprehensive treatment including drug therapy in the postoperative and long‑term periods allow to prevent repeat ischemic cerebrovascular disease and therefore improve patients’ quality of life.

Endovascular outcomes for anterior choroidal artery aneurysms: systematic review and meta-analysis

BackgroundAnterior choroidal artery (AchoA) aneurysms are relatively rare compared to other types of aneurysms. However, the occurrence of transient or permanent occlusion of the choroidal artery during endovascular or surgical treatment is an uncommon but potentially serious complication. In this study, we aim to investigate the safety and efficacy profile of endovascular treatment (EVT) for AchoA aneurysms. MethodsThe primary outcome of interest was angiographic and clinical outcomes. Secondary outcome variables transient and permanent ischemic complications, symptomatic choroidal artery occlusion and retreatment rates. A random-effects model was used to calculate prevalence rates and their corresponding 95 % confidence intervals (CI), and subgroup analyses were performed to assess the complication rates for Type 1(arterial type, directly arising from ICA) and Type 2(neck type, arising from AchoA branch)) AchoA aneurysms, ruptured vs non-ruptured and for flow diverter (FD) treatment versus coiling. ResultsOur study included 10 studies with 416 patients with 430 AchoA aneurysms. The overall good clinical outcome rate (mRS score 0-2) is 94.5 % with a retreatment rate of 2.0 %. A subgroup analysis showed no statistical difference between coiling(75.3 %) and flow diverter(80.9 %) treatment in terms of complete occlusion(p-value:0.62). Overall permanent complication rate is 1.4 % (p-value:0.54) and transient ischemic complications rate is 4.2 %(p-value:0.61). Symptomatic choroidal artery occlusion rate is 0.8 %(p-value:0.51)Type 2 AchoA aneurysms had a significantly higher complication rate of 9.8 % (p-value<0.05) compared to Type 1 aneurysms. Unruptured aneurysms have significantly better clinical outcomes than ruptured aneurysms(OR: 0.11; [0.02;0.5], p-value:<0.05) ConclusionEndovascular treatment of AchoA aneurysms demonstrated positive clinical results, with low rates of retreatment and complications. Coiling and flow diverters proved similar outcomes in achieving aneurysm occlusion. Ruptured aneurysms have lower good clinical outcomes comparing to unruptured aneurysms. Type 2 AchoA aneurysms had a higher risk of complications compared to Type 1.

Open Retrograde Stenting of Proximal Innominate and Common Carotid Artery Stenosis.

The evidence regarding the treatment of open retrograde stenting of innominate artery (IA) or common carotid artery stenosis (CCA) is limited, and is suspected to carry a high risk of stroke and death. Therefore, the objective of this study was to evaluate the outcomes of such hybrid procedures. A retrospective, monocentric study of all patients who underwent retrograde stenting of proximal IA and CCA stenosis via surgical cutdown of the CCA, with or without concomitant CEA, between 2016 and 2023 was performed. Overall, 33 patients were treated. A total of 15 patients (45.5%) were male, with the mean age being 67 ± 9.1 years, and 58% (n = 19) of the patients presented with neurological symptoms. Open retrograde stenting was performed in 67% (n = 22) in ACC, and in 33% (n = 11) in IA stenosis. A total of 20 patients (61%) underwent retrograde stenting with synchronous ipsilateral CEA for concomitant stenosis of the carotid bifurcation. There was no 30-day mortality. The perioperative stroke rate was 3% (n = 1) with complete symptom recovery. During the follow up at 32 months (95% CI: 24-39), three late deaths (9.1%) and one symptomatic stent occlusion were observed and, in five patients (15.2%), re-intervention for restenosis was necessary. Open retrograde stenting for of proximal IA or CCA stenosis with or without CEA, in case of tandem carotid lesions, can be performed safely with a low rate of early adverse events. Continuous follow up examinations are necessary due to relevant instent re-stenosis rates.

Effects and safety of endovascular recanalization for non-acute symptomatic intracranial vertebral artery occlusion with different risks.

There is no consensus on the optimal treatment for non-acute symptomatic intracranial vertebral artery occlusion, and endovascular recanalization is a challenging procedure. We report our clinical experience of endovascular recanalization in patients with non-acute symptomatic intracranial vertebral artery occlusion to assess the feasibility and safety of endovascular recanalization and determine the candidate patients for this procedure. Ninety-two patients with non-acute symptomatic intracranial vertebral artery occlusion who underwent endovascular recanalization from January 2019 to December 2021 were retrospectively analyzed. we grouped all patients according to imaging examination findings, occlusion length, duration, nature, calcification, and angulation to evaluate the risk of endovascular recanalization. The overall success rate of endovascular recanalization was 83.7% (77/92), and the perioperative complication rate was 10.9% (10/92). Among the 3 classification groups, the recanalization success rate gradually decreased from the low-risk group to the high-risk group (low-risk: 100%, medium-risk: 93.3%, high-risk group: 27.8%, P = .047), while the overall perioperative complication rate showed the opposite trend (0%, 10.0%, 38.9%, respectively, P = .001); the proportion of patients with 90-day modified Rankin Scale scores of 0-2 decreased successively (100%, 83.3%, and 22.2%, respectively, P < .026); 77 patients with successful recanalization were followed; the rate of restenosis/reocclusion increased sequentially (0%, 17.9%, and 80%, respectively, P = .000). Patients in the low- and medium-risk groups showed a good clinical course after endovascular recanalization. Among 88 patients (four patients lost to follow-up), with a median clinical follow-up of 13 months (interquartile range ¼, 7-16), the rate of stroke or death after 30 days was 17.4% (16/92). Endovascular recanalization is safe and feasible for low- and medium-risk patients with non-acute symptomatic intracranial vertebral artery occlusion; it is also an alternative to conservative therapy for the patients.

Abstract WP7: Utilization and Outcomes Associated With DAPT and ASA Monotherapy Amongst Hospitalizations With Large Vessel Occlusion: A Nationwide Cross-Sectional Analysis

Background: In clinical trials like SPS3, MATCH, CHANCE, and POINT, dual antiplatelet treatment (DAPT) has been compared to aspirin (ASA) alone for preventing symptomatic large vessel occlusion (LVO) and ischemic strokes. Based on the effect size in the aforementioned studies, nationwide research may provide a more complete assessment of outcomes and relationships and help fill knowledge gaps. We used a nationwide inpatient sample to evaluate the outcomes of symptomatic LVO among patients using DAPT versus ASA monotherapy. Methods: We performed a cross-sectional study of a nationwide inpatient sample (2003-2014) in adult LVO hospitalizations. The patients taking DAPT and ASA on admission were identified using ICD-9-CM code. The univariate analysis (chi-square test) and multivariable survey logistic regression analyses were performed to compare mortality, morbidity, discharge (home vs transfer to short-term hospital, skilled nursing facility, and home health care), and disability to calculate odds ratio with 95% CI using SAS 9.4. Results: Of 4,224,924 hospitalizations, 1.24% and 7.38% were on DAPT and ASA, respectively. In comparison to ASA monotherapy, DAPT users were associated with lower prevalence of mortality (2.2% vs 3.1%) and morbidity (3.8% vs 3.9%) with similar prevalence of discharge to the non-home (58.8% vs 58.8%), (p&lt;0.0001). On weighted analysis, use of DAPT vs. ASA was associated with lower odds of mortality (DAPT: OR 0.45; 95%CI 0.39-0.51; ASA: 0.61, 0.58-0.64), morbidity (DAPT: 0.54, 0.49-0.61, ASA: 0.56, 0.54-0.59), discharge to non-home (DAPT: 0.78, 0.75-0.82, ASA: 0.80, 0.79-0.82), and disability (DAPT: 0.76, 0.73-0.80, ASA: 0.80, 0.78-0.82) compared to non-users. Conclusion: This comprehensive national investigation revealed that DAPT resulted in more favorable outcomes for individuals with symptomatic large vessel occlusion. There is a need for additional prospective studies to validate the findings and ascertain the most suitable population at risk for primary prevention of stroke.