Utility Of Endovascular Treatment Research Articles

Endovascular approach in the management of idiopathic myointimal hyperplasia of the inferior mesenteric vein

BackgroundIdiopathic myointimal hyperplasia of the mesenteric vein (IMHMV) is a rare, often undiagnosed pathology affecting the colon. Patients typically present with severe abdominal pain and inflammation caused by smooth muscle proliferation of the veins, leading to arterialization, stenosis, and potential occlusion. The etiology remains unclear, but it has been hypothesized that an arteriovenous connection may be associated with the pathology. This is the first reported case indicating such an association. This case additionally highlights the potential utility of endovascular treatment, as endovascular embolization is generally a less invasive alternative to surgical resection in the treatment of such vascular disorders.Case PresentationThis report describes a 24-year-old female patient with findings of colitis and an abnormal arteriovenous connection of the inferior mesenteric arterial and venous systems. Partial embolization of this arteriovenous connection temporarily improved the patient’s condition, but her symptoms ultimately returned due to the presence of multiple smaller feeder vessels not amenable to embolization, necessitating colonic resection for definitive treatment. Although prior reports have hypothesized that arterial pressurization of the veins may precipitate myointimal hyperplasia, to the authors’ knowledge, this is the first report of IMHMV with an associated abnormal arteriovenous connection.ConclusionsThis case illustrates the possibility of an association between an arteriovenous connection and IMHMV. This rare diagnosis should be considered in patients with a similar presentation of abdominal pain after common etiologies like IBD have been excluded.

Abstract WP54: National Trends in Utilization and Outcomes of Endovascular Treatment in Acute Ischemic Stroke Patients in Pre- and Post-Stent Retriever Era in the United States

Introduction: Several studies have shown improved outcomes in ischemic stroke patients treated with mechanical thrombectomy in clinical trials after introduction of stent retrievers. The outcomes of patients undergoing endovascular treatment in general practice are expected to improve. We performed this analysis to evaluate trends in utilization of endovascular treatment in acute ischemic stroke and associated rates of death and disability in real world practice. Methods: We obtained data for patients admitted with primary diagnosis of ischemic stroke in United States from 2009-2016 using Nationwide Inpatient Sample. We determined the rate and pattern of utilization, and associated in-hospital outcomes of endovascular treatment among them. Outcomes were classified as minimal disability, moderate to severe disability, and death based on discharge disposition and compared between two time periods: 2009-2011 and 2013-2016 to represent pre and post stent retriever approvals in United States. Results: Of the 3,780,955 patients admitted with ischemic stroke, 244,092 (6.46%) received intravenous thrombolytic treatment, and 48,409 (1.28%) underwent endovascular treatment. There was a fourfold increase in patients who underwent endovascular treatment (0.55% of ischemic strokes in 2009 vs. 2.03% in 2016, trend p < 0.001). In multivariate logistic regression analysis, adjusted for age, gender, thrombolytic therapy, in hospital complications including secondary intracranial hemorrhages, the rate of none to minimal disability improved between the two study intervals (2009-2011 versus 2013-2016), odds ratio (OR) 1.82, 95% confidence interval (CI) 1.47-2.67, p=<0.0001) and moderate to severe disability decreased (OR 0.56, 95% CI 0.45- 0.70, p= <0.0001). There was significant decrease inpatient mortality for patients treated during 2013-2016; OR 0.67, 95% CI 0.56- 0.79, p= <0.0001). Conclusion: There has been a significant increase in the proportion of acute ischemic stroke patients receiving endovascular treatment with improvement of outcomes. Our analysis support generalizability of the successful results observed in clinical trials of endovascular treatment in the post-stent retriever approval era in United States.

Abstract WP41: Age-Specific Differences in the Use of Endovascular Treatment and Hospital Outcomes in Patients With Acute Ischemic Stroke: A Community-Wide Perspective

Background: Relatively limited information is available about trends over time in the use of endovascular treatment in patients of different ages hospitalized with acute ischemic stroke and the association between use of thrombectomy treatment and hospital outcomes in age strata. We performed this analysis to evaluate trends in the utilization of endovascular treatment in acute ischemic stroke by age strata in real-world practice. Methods: We conducted this study by identifying patients admitted with a primary diagnosis of ischemic stroke in the United States from 2007 to 2016 using the Nationwide Inpatient Sample. International Classification of Diseases, ninth revision, and tenth, Clinical Modification (ICD-9-CM, ICD-10-CM) codes were used to identify patients admitted for ischemic stroke and undergoing endovascular treatment. Results: Of the 4,590,533 patients admitted with ischemic stroke, 269,922 (5.88%) received intravenous thrombolytic treatment, and 51,375 (1.12%) underwent endovascular treatment. There is almost 12-fold significant increase in the use of endovascular treatment patients admitted with acute ischemic stroke between 2007 to 2016. Patients who were 75 years and older experienced a marked increase in the receipt of endovascular treatment over time (0.12% 2007; 1.91% 2016; trend p<0.0001). We observed statistically significant improvement in outcomes including minimal disability (6.3% to 18.8%; trend p<0.0001) and in hospital mortality (25.0% to 16.5%; trend p<0.0001) in patients 75 years and older treated with endovascular treatment in study period. We observed similar trend of outcomes in each of the other age-specific groups under study (<55, 55-64 and 65-74 years). Conclusions: Our findings indicate a recent increase in the use of endovascular in middle-aged and elderly patients with acute ischemic strokes. The impact of endovascular treatment on hospital outcomes was observed in each of our age strata understudy though the magnitude of absolute and relative benefit varied according to age.

Abstract WP284: National Trends in Utilization and Outcomes of Thrombolytic Use by Drip and Ship Paradigm in Acute Ischemic Stroke Patients in United States

Background and Purpose: The drip and ship paradigm has rapidly expanded in the last decade allowing higher thrombolytic utilization and endovascular treatment. We performed this analysis to evaluate trends in utilization of drip and ship paradigm in United States and associated outcomes. Methods: We analyzed data for patients admitted with primary diagnosis of ischemic stroke in the United States from Nationwide Inpatient Sample, the largest nationally representative data, for the years 2009 to 2015. We studied changes in utilization of drip-and-ship paradigm and subsequent performance of endovascular treatment, and rates of discharge with none to minimal disability and moderate to severe disability. Results: Of the 3,043,190 patients admitted with ischemic stroke, 56,449 (1.85%) patients received thrombolytic treatment through drip-and-ship paradigm over a 7 year period. Of all patients who received thrombolytic treatment (n=243,824), 56,449 (23.15%) received using drip and ship paradigm. There was almost 3 fold increase in drip and ship paradigm (in 0.98% 2009 to 2.80% in 2015 (test for trend= p < 0.001). Among the patients who underwent drip and ship paradigm, 5,061 (8.97%) underwent endovascular treatment. The rate of endovascular treatment increased from 6.62% to 12.39% among patients treated with drip and ship paradigm (test for trend= p < 0.001). The rate of none minimal disability at discharge increased from 39.93% to 47.08%, (test for trend p < 0.001) while moderate to severe disability decreased 51.22% to 47.08%, (test for trend p < 0.001) in ischemic stroke patients treated using drip-and-ship paradigm. Similar trends were observed for hospital outcomes in multivariate logistic regression model, adjusted for age, gender, medical comorbidities and secondary intracranial hemorrhages. Conclusion: There has been a significant increase in the proportion of acute ischemic stroke patients treated using drip-and-ship paradigm (out of proportion to overall thrombolytic use) with increase in subsequent endovascular treatment in United States. The in hospital outcomes of patients have improved perhaps due to higher utilization of endovascular treatment.

Distribution and current problems of acute endovascular therapy for large artery occlusion from a two-year national survey in Japan.

Endovascular treatment is recommended in clinical practice in Japan. However, its utilization and comprehensiveness are less well described. To report endovascular treatment utilization and overall geographical coverage in Japan and to analyze regional differences in the number of endovascular treatments, specialists, and endovascular treatment-capable hospitals. A national survey of members of the Japanese Society for NeuroEndovascular Therapy (JSNET) was conducted in 2017 and 2018. The total number of endovascular treatment cases per year was estimated, and the number of endovascular treatment cases per 100,000 people was calculated using the 2015 census. The distribution of treatment hospitals and JSNET specialists was mapped and the population coverage rate was determined. The total number of endovascular treatment cases in Japan increased by 34.5% from 2016 (7702) to 2017 (10,360). The number of endovascular treatment-capable hospitals in Japan increased from 597 in 2016 to 693 in 2017, with an average annual caseload of 14.9 in 2017. The number of JSNET specialists per hospital decreased from 1.81 in 2016 to 1.76 in 2017 because of the increase in endovascular treatment-capable hospitals. Only 50 (7.2%) hospitals had > 40 endovascular treatment cases annually. The majority (97.7%) of the Japanese population lives within a 60-min drive of any endovascular treatment-capable hospital. However, only 70.4% live within a 60-min drive of a high-volume center (>40 cases annually). Utilization of endovascular treatment in Japan is increasing; however, the number of cases per hospital remains low, as is the number of specialists per endovascular treatment-capable hospital. Increased number of specialists and centralization of endovascular treatment services may improve patient outcomes.

Abstract WP164: Validation of Noninvasive Methods of Intracranial Stenosis Measurement Against Conventional Angiography

Introduction: Stenosis caused by intracranial atherosclerotic plaques has long driven treatment algorithms. Conventional digital subtraction angiography (DSA) is considered the gold standard for measuring such stenosis, but fewer patients are evaluated with this modality as utilization of endovascular treatment has decreased. Vessel wall MRI (VWMRI) offers improved characterization by allowing inspection of the vessel wall and disease itself rather than narrowing of the lumen. This study compares measurements of stenosis in VWMRI against those made on conventional angiography or older noninvasive imaging techniques. Methods: VWMRI studies performed for patients with plaques that had caused a stroke were retrospectively analyzed. Stenoses were measured according to the WASID technique on DSA, post-contrast T1 DANTE, non-contrast time of flight (TOF), post-contrast TOF, and CTA images. Intraclass correlation coefficient (ICC), weighted kappa, and Cohen’s kappa were calculated as appropriate to assess agreement among stenosis measurements on these techniques. Results: Studies from 54 patients met inclusion criteria. Mean stenosis as measured by post-contrast T1 DANTE was 53.8% (±23.2%). 13 (24.1%) had stenosis ≥70%. ICC analysis of agreement between stenosis measurements on DSA demonstrated highest agreement with post-contrast T1 DANTE (ρ=0.927) and CTA (ρ=0.935), with excellent agreement also seen with post-contrast (ρ=0.915) and non-contrast TOF (ρ=0.8110). When separating measurements into ≥70% or <70%, agreement was highest for CTA (κ=1.0) and post-contrast T1 DANTE (κ=0.857), and post-contrast TOF (κ=0.857), while non-contrast TOF agreement was much lower (κ=0.400). Classifying stenosis ordinally by quartiles, greatest agreement with DSA as identified by weighted kappa analysis was seen with post-contrast T1 DANTE (wκ=0.331), followed by post-contrast TOF (wκ=0.268), CTA (wκ=0.253), and non-contrast TOF (wκ=0.222). Conclusion: Contrast-enhanced noninvasive angiographic techniques had greatest agreement with DSA when measuring plaque stenosis, with best agreement seen with post-contrast T1 DANTE and CTA. Non-contrast TOF agreement was inferior. The majority (75.9%) of symptomatic lesions had stenosis <70%.

Statewide trends in utilization of endovascular treatment and outcomes: Analysis of Minnesota Hospital Association data (2014 and 2015) (P5.270)

Statewide trends in utilization of endovascular treatment and outcomes: Analysis of Minnesota Hospital Association data (2014 and 2015) (P5.270)

Abstract TP33: Statewide Trends in Utilization of Endovascular Treatment and Outcomes: Analysis of Minnesota Hospital Association Data (2014 and 2015)

Background: There is emphasis on understanding the implementation of clinical trial results for clinical practice. The aim of this study is to examine the changes in endovascular procedures utilization after the publication of the recent clinical trials showing benefit of such procedures in patients with acute ischemic stroke (AIS). Methods: Minnesota Hospital Association (MHA) database was used to calculate the state wide utilization rates for two periods: prior to (January 1st-December 31st, 2014) and after (January 1 st -December 31 st , 2015) publication of randomized clinical trials. MHA collects data from 137 member hospitals for monitoring and reporting healthcare quality and cost across the state. Patients with admitting diagnosis of AIS and those who received endovascular treatment were identified using ICD9 or ICD10 codes. Utilization rates for endovascular treatment were calculated monthly, quarterly, and annually. Discharge to home was considered as the measure of none to minimal disability. Results: Of the 13,043 patients admitted with the diagnosis of AIS, 434 patients (mean age 68.5± 25.5 years; 51.2% women) received endovascular treatment. The number of procedures increased from 194 in 2014 to 240 in 2015. Utilization rate was 3.4% in the first quarter of 2014, gradually declined to reach its lowest value (2.6%) in the last quarter of 2014, then steadily increased to reach its peak (4%) in the last quarter of 2015. Procedures performed at comprehensive stroke centers increased from 52% of total procedures in 2014 to 57.5% in 2015 while those performed at primary stroke centers decreased from 22.6% in 2014 to 19.5% in 2015. In 2015, fewer patients had hypertension (50.4% vs. 60.3%; p=0.039) and more patients had chronic kidney disease (28.3% vs. 15.5%; p=0.001). Intracranial hemorrhage and mortality rates were not significantly different between the two years. There was a trend towards higher rate of minimal or no disability at discharge among patients treated in 2015 compared with those treated in 2014 (22.5% versus 18.1%, p=0.25). Conclusion: We observed a state wide increase in rate of utilization of endovascular treatment of AIS patients coinciding with the publication of the results of new clinical trials.

Ophthalmic systems completely supplied from dural arteries indicate the utility of endovascular treatment of cerebral aneurysms

We report a 67-year-old man who harboured an unruptured left basilar-superior cerebellar artery aneurysm. Cerebral angiography and cone beam computed tomography with diluted contrast medium showed that the bilateral ophthalmic arteries were not supplied from internal carotid arteries but, rather, were supplied from the middle meningeal and accessory meningeal arteries. This meant that the ophthalmic system was predominantly supplied from the dural arteries and, therefore, pterional craniotomy might cause a compromise in blood supply to the retinal artery. To avoid this complication, coil embolization was selected instead of neck clipping, and this endovascular therapy succeeded without neurological deficit. This case report shows the importance of cerebral angiography (including cone beam computed tomography) and consideration of the patterns of ophthalmic artery perfusion when selecting operative procedures for management of aneurysms that require manipulation around the sphenoid ridge.

Abstract W MP2: Unchanged Utilization of Endovascular Treatment in Acute Ischemic Stroke Patients in the post IMS-III era

Background: The results of Interventional Management of Stroke (IMS) III, MR RESCUE, and SYNTHESIS EXPANSION trials are expected to affect the utilization of endovascular treatment for acute ischemic stroke. Objective: To evaluate trends in utilization of endovascular treatment among acute ischemic stroke patients after the publication of IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials. Methods: We obtained data for patients admitted to hospitals with a primary diagnosis of ischemic stroke using data from Minnesota Hospital Association. We determined the rate of utilization of endovascular treatment for acute ischemic stroke from March 2012 to December 2012 and March 2013 to December 2013. Outcomes were classified based on discharge disposition. Results: Of the 13,408 patients with ischemic stroke, 6765 (50.5%) were admitted with ischemic stroke prior to, and 6643 (49.5%) after the publication of trials’ results. The proportion of patients who underwent endovascular treatment was unchanged: 2.3% of ischemic stroke patients in the pre-IMS III group vs 2.4% in the post-IMS III group (p=0.6). The estimated number of patients undergoing any thrombolytic treatment increased (7.1% versus 7.8%,p=0.1). There was a significant reduction in length of stay in the post IMS III group, 3.8 ± 4.1 vs 3.6 ± 3.5 (p=0.02). The rates of discharge to home remained unchanged in the pre- and post- IMS III groups (3646 (53.9%) vs 3585 (54.0%), p=0.9). Conclusion: Contrary to expectations, there has been no reduction in the utilization of endovascular treatment among acute ischemic stroke patients after IMS-III, MR RESCUE and SYNTHESIS EXPANSION results were published.

National Trends in Utilization and Outcomes of Endovascular Treatment of Acute Ischemic Stroke Patients in the Mechanical Thrombectomy Era

Because several new devices for mechanical thrombectomy have become available, the outcomes of patients undergoing endovascular treatment for acute ischemic stroke are expected to improve in the United States. We performed this analysis to evaluate trends in utilization of endovascular treatment and associated rates of death and disability among acute ischemic stroke patients over a 6-year period, including further assessment within age strata. We obtained data for patients admitted to hospitals in the United States from 2004 to 2009 with a primary diagnosis of ischemic stroke using a large national database. We determined the rate and pattern of utilization, and associated in-hospital outcomes of endovascular treatment among ischemic stroke patients and further analyzed trends within age strata. Outcomes were classified as minimal disability, moderate to severe disability, and death based on discharge disposition and compared between 2 time periods: 2004 to 2007 (post-MERCI) and 2008 to 2009 (post-Penumbra) approvals Of the 3,292,842 patients admitted with ischemic stroke, 72,342 (2.2%) received intravenous thrombolytic treatment and 13 799 (0.4%) underwent endovascular treatment. There was a 6-fold increase in patients who underwent endovascular treatment (0.1% of ischemic strokes in 2004 vs 0.6% in 2009; P<0.001), with the patients aged≥85 years having the lowest rate of utilization (0.2%). The rates of intracranial hemorrhage remained unchanged throughout the 6 years. In multivariate logistic regression analysis, after adjusting for age, gender, presence of hypertension, congestive heart failure, renal failure, and secondary intracranial hemorrhages, there was no difference in the rate of minimal disability between the 2 study intervals (2004-2007 vs 2008-2009; odds ratio, 0.8; 95% confidence interval, 0.7-1.04; P=0.11). Mortality decreased while moderate to severe disability increased for patients treated during 2008 to 2009 (odds ratio, 0.7; 95% confidence interval, 0.6-0.9; P=0.007; and odds ratio, 1.4; 95% confidence interval, 1.2-1.7; P=0.0002). There has been a significant increase in the proportion of acute ischemic stroke patients receiving endovascular treatment over the 6 years and reduction in in-hospital mortality. Our results highlight the need to implement endovascular techniques in a balanced manner across various age groups that also results in the reduction of disability in addition to mortality.

Abstract 140: National Trends in Utilization and Outcomes of Endovascular Treatment in Acute Ischemic Stroke Patients

Background: With the availability of several new devices for mechanical thrombectomy after recent approvals by the Food and Drug Administration, the outcomes of patients undergoing endovascular treatment for acute ischemic stroke are expected to improve in United States. Objective: To evaluate trends in utilization of endovascular treatment and associated rates of death and disability among acute ischemic stroke patients over six years. Methods: We obtained data for patients admitted to hospitals in the United States between 2004 to 2009 with a primary diagnosis of ischemic stroke using a large national database. We determined the rate of utilization of endovascular treatment. Outcomes were classified as minimal disability, moderate to severe disability, and death based on discharge disposition. Results: Of the 670,069 patients with ischemic stroke, 72,342 (10.8%) received intravenous thrombolytic treatment, 18,229 (2.72%) had endovascular thrombolysis. Patients with endovascular treatment comprised 0.35% of ischemic strokes in 2004 vs 4.95% in 2009 (p &lt; 0.001). The estimated number of patients undergoing endovascular treatment increased by 1,519% (362 to 5502) despite a 324% increase in patients receiving intravenous thrombolytic. The rates of intracranial hemorrhage remained unchanged throughout the 6 years. There was no significant difference in all age groups. The interaction between endovascular treatment among all ischemic stroke patients for predicting in-hospital mortality significantly improved (p &lt;0.02). Conclusion: There has been a significant increase in proportion of acute ischemic stroke patients receiving endovascular treatment over the last 6 years with significant reduction in in-hospital mortality.