Stenting the carotid artery from radial access using a Simmons guide catheter.

BACKGROUND: Carotid artery stenting (CAS) is a procedure for stroke prevention, usually done from femoral artery access. Reports of CAS using radial artery access have adopted techniques similar to those used for transfemoral CAS. Initial experience with a simpler and lower profile technique for transradial carotid stenting is described here. METHODS: Of 55 consecutive elective CAS cases with standard (not bovine) arch anatomy performed during a 15 month time period by the same operator, 20 were selected for transradial treatment using a 6 F Simmons 2 guide catheter. This was a retrospective analysis of those initial 20 patients compared with the 35 patients treated with elective transfemoral CAS. The CAS database was reviewed for clinical indications, technique, procedure and fluoroscopy times, and clinical outcomes. RESULTS: All procedures were technically successful (no crossovers). No patient had a decline in National Institutes of Health Stroke Scale score or modified Rankin Scale score within 30 days. Mean (95% CI) procedural times for transradial CAS were slightly higher than transfemoral CAS (29.4 (26.0 to 32.7) vs 23.8 (21.2 to 26.4) min, p=0.0098). Mean (95% CI) fluoroscopy times were also higher for transradial CAS compared with transfemoral CAS (9.6 (8.0 to 11.2) vs 6.4 (5.4 to 7.4), p=0.0006). One patient developed a radial artery pseudoaneurysm which required elective surgical repair. CONCLUSION: Transradial carotid stenting using the described lower profile technique provides another effective option in the array of surgical procedures for the treatment of carotid artery stenosis. Relative procedural and fluoroscopy times may initially be longer compared with transfemoral carotid stenting for experienced CAS operators, although absolute differences are small.

Carotid stenosis, stroke, and carotid artery revascularization.

Atherosclerotic disease of the carotid artery places patients at risk of ischemic stroke and consequently is a target of medical, endovascular and open surgical management. Various imaging modalities are used to characterize anatomy/severity of carotid disease and justify intervention, each having advantages and disadvantages. Carotid revascularization techniques including carotid artery stenting, carotid endarterectomy, and transcarotid artery revascularization vary in invasiveness and are not equally suitable for certain subsets of patients. As such, providing quality care for patients with carotid disease requires a multidisciplinary team of experts in clinical diagnosis, image interpretation, medical management, endovascular intervention, and surgical treatment.

Imaging criteria across pivotal randomized controlled trials for late window thrombectomy patient selection.

BACKGROUND: The DAWN and DEFUSE-3 trials showed the benefit of endovascular treatment (EVT) in acute ischemic stroke patients presenting beyond 6 hours from last known well (LKW) and selected by perfusion imaging criteria. The ESCAPE NA1-trial selected patients based on non-contrast CT (NCCT) Alberta Stroke Program Early CT Score (ASPECTS) and multiphase CT angiography (CTA) collateral status. This study compares baseline characteristics, workflow, and outcomes in the EVT arms of DAWN and DEFUSE-3 with late-window patients from the EVT-only arm of ESCAPE-NA1. METHODS: Aggregate data on baseline characteristics, workflow, reperfusion quality, final infarct volume, and clinical outcomes (modified Rankin Score [mRS] at 90 days) in subjects enrolled in the DAWN and DEFUSE-3 EVT arms were compared with similar data from the ESCAPE-NA1 control arm (EVT-only arm) presenting beyond 6 hours from LKW using descriptive statistics. RESULTS: Baseline characteristics among late-window patients in the ESCAPE NA1 trial were similar to those in the DAWN and DEFUSE-3 EVT arms. Median time from LKW-to-puncture in subjects enrolled in the ESCAPE NA1 trial was 9 hrs (IQR: 7.5-11 hours) when compared with DAWN (n=107; 12.8 hours, IQR: 10.6-16.7 hours) and DEFUSE-3 (n=92; 11.5 hours, IQR: 9.2-12.8 hours). Median post-treatment infarct-volume was largest in the ESCAPE NA1-patients (47 mL [IQR: 19-146] vs median 8 mL [IQR: 0-48] in the DAWN group and 35 mL [IQR: 18-82] in DEFUSE-3), while % mRS 0-2 at 90 days were similar across the three trials (ESCAPE NA1: 50/111 [45%], DAWN: 52/107 [49%], DEFUSE-3: 41/92 [45%]). CONCLUSION: Patients enrolled beyond 6 hours from LKW in the ESCAPE-NA1 trial based on NCCT-ASPECTS and mCTA had similar clinical outcomes when compared with patients selected by perfusion imaging in the DAWN and DEFUSE-3 trials.

Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery.

OBJECTIVE: To summarize the current literature regarding the initial hospital management of patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO), and to offer recommendations designed to decrease the time to endovascular treatment (EVT) for appropriately selected patients with stroke. METHODS: Using guidelines for evidenced-based medicine proposed by the Stroke Council of the American Heart Association, a critical review of all available medical literature supporting best initial medical management of patients with AIS secondary to ELVO was performed. The purpose was to identify processes of care that most expeditiously determine the eligibility of a patient with an acute stroke for interventions including intravenous fibrinolysis with recombinant tissue plasminogen activator (IV tPA) and EVT using mechanical embolectomy. RESULTS: This review identifies four elements that are required to achieve timely revascularization in ELVO. (1) In addition to non-contrast CT (NCCT) brain scan, CT angiography should be performed in all patients who meet an institutional threshold for clinical stroke severity. The use of any advanced imaging beyond NCCT should not delay the administration of IV tPA in eligible patients. (2) Activation of the neurointerventional team should occur as soon as possible, based on either confirmation of large vessel occlusion or a prespecified clinical severity threshold. (3) Additional imaging techniques, particularly those intended to physiologically select patients for EVT (CT perfusion and diffusion-perfusion mismatch imaging), may provide additional value, but should not delay EVT. (4) Routine use of general anesthesia during EVT procedures, should be avoided if possible. These workflow recommendations apply to both primary and comprehensive stroke centers and should be tailored to meet the needs of individual institutions. CONCLUSIONS: Patients with ELVO are at risk for severe neurologic morbidity and mortality. To achieve the best possible clinical outcomes stroke centers must optimize their triage strategies. Strategies that provide patients with ELVO with the fastest access to reperfusion depend upon detail-oriented process improvement.

The SPEED study: initial clinical evaluation of the Penumbra novel 054 Reperfusion Catheter.

BACKGROUND AND PURPOSE: Revascularization of acute ischemic stroke from a large vessel occlusion continues to be a challenge with current thrombectomy devices. The purpose of the SPEED study was to report the safety and effectiveness of the Penumbra 054 Reperfusion Catheter System in revascularizing large vessel occlusions. METHODS: In this retrospective multicenter study, data were collected from patients with angiographic evidence of large vessel occlusion treated with the Penumbra 054 device as the intended primary therapy. Clinical outcome data were collected with 90-day follow-up and the results were compared with those from the Penumbra Pivotal trial. RESULTS: Eighty-seven target vessels in 86 consecutive patients treated with the Penumbra 054 device were included. The Thrombolysis In Myocardial Infarction (TIMI) 2 or 3 revascularization rate was 91% compared with a reported 82% in the Penumbra Pivotal trial. This was accomplished in a median time of 20 min compared with 45 min in the Penumbra Pivotal trial (p<0.0001). Eighteen (21%) patients experienced an intracranial hemorrhage of which 12 (14%) were symptomatic. Good neurologic outcome (modified Rankin scores ≤ 2) at 90-day follow-up was achieved in 34.9% of patients compared with 25% reported in the Penumbra Pivotal trial. All-cause mortality was 25.6%. CONCLUSIONS: These results suggest that the Penumbra 054 is a fast, safe and effective revascularization tool for patients experiencing ischemic stroke secondary to large vessel occlusive disease. Improvements in speed and effectiveness of revascularization probably contributed to improved outcomes.

The Penumbra Stroke System: a technical review.

Major ischemic strokes secondary to proximal artery occlusions are responsible for significant morbidity and mortality. Owing to extensive clot burden, these strokes are poorly responsive to intravenous tissue plasminogen activator. The introduction of endovascular therapy, particularly mechanical devices, has resulted in markedly improved recanalization rates of large vessel occlusions. With increasing experience with the Penumbra Stroke System and the 054 reperfusion catheter, there has been further improvement in TIMI 2 and 3 revascularization rates with faster times to vessel opening. The aim of this technical review is to convey various tips and tricks learnt from this experience.

Superior bronchial artery arising from the left common carotid artery: embryology and clinical considerations.

A bronchial artery arising from the left common carotid artery was incidentally documented during cerebral angiography in a 64-year-old patient. This variant can be understood as the adult persistence of a primitive bronchial branch arising from the third branchial arch. It represents a potential pitfall for the identification and treatment of the bleeding source in patients with hemoptysis.