Treatment of ruptured subclavian steal flow-related vertebrobasilar junction aneurysms: Case report on surgical and endovascular considerations from two cases.

INTRODUCTION: Subclavian steal phenomenon causes retrograde flow through the vertebral artery, ipsilateral to the affected subclavian artery, which rarely leads to flow-related vertebrobasilar junction (VBJ) aneurysms. CASE DESCRIPTIONS: We describe two cases of subarachnoid hemorrhage from such ruptured aneurysms in which the retrograde flow direction in the vertebral artery complicated surgical and endovascular treatment. DISCUSSION: Reversed flow in the vertebral artery, ipsilateral to the stenotic subclavian artery leads to a lack of proximal control in surgical clipping of these VBJ aneurysms and jeopardizes stability of coil and stent placement in endovascular aneurysm treatments in this setting. CONCLUSION: From these 2 experiences over 7 years, treatment considerations emerged for future cases.

The Woven EndoBridge for unruptured intracranial aneurysms: Results in 95 aneurysms from a single center.

BACKGROUND AND PURPOSE: The Woven EndoBridge (WEB) is an intrasaccular flowdisruptor that is increasingly used for the treatment of (wide-necked) aneurysms. We present our experience with the WEB for unruptured aneurysms. MATERIALS AND METHODS: Between April 2014 and August 2019, 93 patients with 95 unruptured aneurysms were primarily treated with the WEB. There were 69 women and 24 men, mean age 61 years (median 58, range 37-80). RESULTS: Of 95 aneurysms, 86 had been discovered incidentally, 3 were symptomatic and 6 were additional to another ruptured aneurysm. Location was anterior communicating artery 33, middle cerebral artery 29, basilar tip 19, carotid tip 8, posterior communicating artery 4, posterior inferior cerebellar artery 1, superior cerebellar artery 1. Mean aneurysm size was 6 mm (median 6, range 3-13 mm).In one aneurysm additional coils were used and in another, a stent was placed. There was one procedural rupture without clinical sequelae. There were two thrombo-embolic complications leading to permanent deficit in one patient (mRS 2). Morbidity rate was 1.0% (1 of 93, 95%CI 0.01-6.5%) and mortality was 0% (0 of 93, 95%CI 0.0-4.8%). Angiographic follow-up at six months was available in 85 patients with 87 aneurysms (91%). Of 87 aneurysms, 68 (78%) were completely occluded, 14 (16%) had a neck remnant and 5 were incompletely occluded. Four aneurysms were retreated. Retreatment rate was 4.5% (4 of 87, 95%CI 1.7-13.6%). CONCLUSION: WEB treatment of unruptured aneurysms is safe and effective. Additional devices are needed only rarely and retreatment at follow-up is infrequent.

Multicenter, retrospective analysis of endovascular treatment for acute ischemic stroke in nonagenarians.

BACKGROUND: With the increasing age of acute stroke patients being admitted to hospitals, more data are needed on indications, complications and outcome of endovascular treatment (EVT) in the very elderly. METHODS: Retrospective observational study with data collection from Belgian, Swiss, Canadian comprehensive stroke centers and Swedish EVT National database. All patients with acute ischemic stroke were eligible if aged older than or ≥90 years and treated with EVT ± pretreatment with intravenous thrombolysis (IVT). Safety assessment comprised presence of periprocedural complications, hemorrhagic transformation or other adverse events (<7days). Efficacy and outcome measures were successful recanalization (modified Treatment In Cerebral Infarction (mTICI) score ≥2b), favorable clinical outcome (modified Rankin Score (mRS) 0-2) and 3-months mortality. RESULTS: Inclusion of 112 nonagenarians (mean age 93.3 ± 2.5 years; 76.8% women; pre-mRS ≤2 in 69.4%). Pretreatment with IVT was performed in 54.7%. In 74.6% successful recanalization (mTICI ≥2b) was achieved. Favorable outcome (mRS ≤2) was seen in 16.4% and 3-months mortality was 62.3%. Multivariate logistic regression analysis showed younger age (odds ratio [OR] 2.99; 1.29-6.95; P = .011) and lower prestroke mRS (OR 13.46; 2.32-78.30; P = .004) as significant predictors for good clinical outcome at 90 days. CONCLUSIONS: Our observational study on EVT in nonagenarians demonstrates the need for careful patient selection. A substantial proportion of nonagenarians shows an unfavorable clinical outcome and high mortality, despite acceptable recanalization rates. A high prestroke disability (mRS) and advancing age predict an unfavorable outcome. Treatment decisions should be made on case-by-case evaluation, keeping in mind limited chances of favorable outcome and high risk of mortality.

Alberta Stroke Program Early CT Score Versus Computed Tomographic Perfusion to Predict Functional Outcome After Successful Reperfusion in Acute Ischemic Stroke.

Background and Purpose- We aimed to compare the ability of conventional Alberta Stroke Program Early CT Score (ASPECTS), automated ASPECTS, and ischemic core volume on computed tomographic perfusion to predict clinical outcome in ischemic stroke because of large vessel occlusion ≤18 hours after symptom onset. Methods- We selected patients with acute ischemic stroke from the CRISP study (Computed Tomographic Perfusion to Predict Response to Recanalization in Ischemic Stroke Project) with successful reperfusion (modified treatment in cerebral ischemia score 2b or 3). We used e-ASPECTS software to calculate automated ASPECTS and RAPID software to estimate ischemic core volumes. We studied associations between these imaging characteristics and good outcome (modified Rankin Scale score, 0-2) or poor outcome (modified Rankin Scale score, 4-6) in univariable and multivariable analysis, after adjustment for relevant clinical confounders. Results- We included 156 patients. Conventional and automated ASPECTS was not associated with good or poor outcome in univariable analysis ( P=nonsignificant for all). Automated ASPECTS was associated with good outcome in multivariable analysis ( P=0.02) but not with poor outcome. Ischemic core volume was associated with good ( P<0.01) and poor outcome ( P=0.04) in univariable and multivariable analysis ( P=0.03 and P=0.02, respectively). Computed tomographic perfusion predicted good outcome with an area under the curve of 0.62 (95% CI, 0.53-0.71) and optimal cutoff core volume of 15 mL. Conclusions- Ischemic core volume assessed on computed tomographic perfusion is a predictor of clinical outcome among patients in whom endovascular reperfusion is achieved ≤18 hours after symptom onset. In this population, conventional or automated ASPECTS did not predict outcome.

The Value of the Middle Meningeal Artery in Cerebrovascular Bypass Surgery: An Anatomic Feasibility Study.

BACKGROUND: Over the past decade, there has been a revival and a renewed interest for cerebrovascular bypass procedures. The superficial temporal artery (STA) has its value as a reliable donor vessel; however, a possible role for the middle meningeal artery (MMA) as a donor artery is still unclear. OBJECTIVE: To assess the feasibility of using the MMA as a donor vessel in cerebrovascular surgery. METHODS: We performed cadaveric dissections on 12 fresh specimens (23 sides) after bilateral silicone injection into the internal and external carotid arteries. We compared the size, diameter, and possibility to perform a bypass to the middle cerebral artery for both the MMA and the STA. Measurements were done using an electrical caliper. Additional measurements of the MMA and STA were performed on 20 random angiograms. RESULTS: There was no statistically significant difference in diameter of the MMA at its ostium being 2.4 mm, compared to 2.7 mm for the STA ostium (t-test; P = .21). The MMA could be mobilized over 4.1 cm, whereas the STA over 8.3 cm. Finally, the mean diameter of the donor vessel at the site of the anastomosis was 1.6 mm versus 1.9 mm for MMA and STA, respectively (P = .0026). We were able to perform an MMA and middle cerebral artery anastomosis on 17 sides. CONCLUSION: These results suggest that the MMA is a potentially valuable donor vessel to be used in selected cases. The availability of a suitable MMA branch should be assessed preoperatively on the angiogram.

Evaluation and clinical correlation of practical cut-offs for visual rating scales of atrophy: normal aging versus mild cognitive impairment and Alzheimer's disease.

Age-related brain atrophy is a common finding, but neurodegenerative diseases such as Alzheimer's disease are associated with accelerated atrophy of the medial temporal lobe. In current practice for brain atrophy evaluation, several rating scales are being used such as the medial temporal atrophy (MTA), global cortical atrophy-frontal subscale (GCA-F) and posterior atrophy (PA) scales. Practical cut-offs to differentiate between normal and advanced brain atrophy are needed, because of their possible usefulness as a biomarker. A retrospective study was performed over a 1-year period resulting in a total of 79 subjects [27 patients with Alzheimer's disease (AD), 27 patients with minimal cognitive impairment (MCI) and 25 control subjects]. The MTA, GCA-F and PA scales were applied blinded and independent by two raters. Possible age- and disease-related cut-offs were computed. The MTA scale showed significantly better diagnostic performances and inter-rater agreement than the PA and GCA-F scales. We could not confirm the suggested MTA cut-off for each decade. However, an MTA score of >1 and >1.75 was considered pathological, respectively, in the population under and over 70 years. MTA can be of use in making distinction between age-related atrophy and abnormal increase of atrophy. Systematic assessment of regional brain atrophy through the use of MTA in MRI images could be a useful biomarker in aiding the early diagnosis of Alzheimer's disease.

Expanded polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunts in cirrhotic patients: Long-term patency and clinical outcome results.

PURPOSE: To retrospectively analyse long-term patency and overall survival of cirrhotic patients treated with TIPSS using e-PTFE-covered stents. Additionally, prognostic factors for better patency and survival were analysed. MATERIALS AND METHODS: Two hundred and eighty-five consecutive cirrhotic patients with severe portal hypertension-related symptoms were included. Follow-up, including clinical assessment and duplex ultrasound, was analysed up to end of study, patient's death, liver transplantation or TIPSS-reduction. Patency rates and overall survival were estimated by the Kaplan-Meier method; potential differences in outcome between subgroups were calculated using the Pepe and Mori test. RESULTS: The 1-, 2- and 5-year primary patencies were 91.5 %, 89.2 % and 86.2 %, respectively, with no new shunt dysfunctions after 5 years' follow-up. TIPSS revision was performed more often in ascites patients (P = 0.02). The 1-, 4- and 10-year survival rates were 69.2 %, 52.1 % and 30.7 %, respectively. Survival was higher in Child-Pugh class A-B (P = 0.04), in the recurrent bleeding group (P = 0.008) and in patients with underlying alcoholic cirrhosis (P = 0.01). CONCLUSION: Long term, primary patency of e-PTFE-covered TIPSS stents remains very high (>80 %); shunt revision was required more frequently in ascites patients. Overall survival was better in Child-Pugh A-B patients with recurrent variceal bleeding and alcoholic liver cirrhosis. KEYPOINTS: • Long-term primary patency rate of e-PTFE-covered TIPSS stents remains very high. • No new shunt dysfunction was found after 5 years of follow-up. • Shunt revision was required more frequently in ascites patients. • Four and 10 years' overall survival was 50 and 30 %, respectively.

Long-term clinical and radiological outcome of endovascular embolization of pancreatitis-related pseudoaneurysms.

Background Long-term outcome after embolization of pancreatitis-induced pseudoaneurysm is not yet determined. Purpose To assess the long-term efficacy and patients' overall survival after embolization of pancreatitis-induced pseudoaneurysm. Material and Methods Patients referred for endovascular treatment of a pancreatitis-induced pseudoaneurysm between January 1998 and January 2014 were analyzed. Embolization procedures were performed by transcatheter techniques using different types of embolic agents. Demographic, technical-radiological, and clinical data were collected. Results Thirty-four patients were identified with a pancreatitis-induced pseudoaneurysm; the underlying disease was acute (n = 13; 38%) or chronic (n = 21; 62%) pancreatitis; seven patients (20.6%) had active bleeding when embolized, while in the remaining 27 patients (79.4%) the pseudoaneurysm was not bleeding. In all 34 patients, successful endovascular exclusion of the pseudoaneurysm was obtained after the first attempt. Minor complications occurred in 11 patients (30%); no major complications were noted. A new pseudoaneurysm on a different vessel was identified during follow-up in three patients (9%). In another patient (3%), the excluded pseudoaneurysm reopened during follow-up. All four recurrences occurred within the first 5 months after embolization. Long-term follow-up (mean, 6.6 years; range, 4 months-16 years) revealed estimated survival rates of 94%, 89%, and 75% after 2, 5, and 10 years respectively, without pseudoaneurysm-related death. Conclusion Catheter-directed embolization of pancreatitis-induced pseudoaneurysms is relatively safe and effective. Recurrence or new pseudoaneurysm formation was low and occurred within the first 6 months after embolization. Overall survival is high, with no pseudoaneurysm-related deaths.

Percutaneous shunt reduction for the management of TIPS-induced acute liver decompensation: A follow-up study.

 Background and rationale for the study. The purpose of this study was to assess the technical and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) reduction for the management of TIPS-induced acute liver decompensation. Between August 2000 and November 2013, 347 patients underwent a TIPS procedure in the authors' institution; 21/347 (6%) developed post-TIPS acute liver decompensation which was managed using a percutaneous shunt reduction technique. Patient demographics, laboratory tests before and after initial TIPS and TIPS reduction, procedural data and clinical follow-up data were analysed. RESULTS: Twenty-one patients (mean age 63 years) who underwent an initial TIPS procedure for variceal bleeding (n = 7; 33%) or refractory ascites (n = 14; 67%) successfully underwent shunt reduction ten days (3-34 days) after the initial TIPS procedure. The portosystemic pressure gradient (PSPG) increased from 8 (3-17) mmHg before reduction to 12 (7-23) mmHg after shunt reduction. Survival at one and six months follow-up was 15 (71%) and 11 patients (52%), respectively. The international normalised ratio (INR) (1.7 vs. 1.5; p = 0.044) was significantly different after TIPS reduction in the non-survival group compared to the survival group. In conclusion, TIPS reduction for the management of TIPS-induced acute liver decompensation is technically feasible and is associated with a one and six-month mortality rate of 29% and 48%, respectively. Higher post-TIPS-reduction INR values may be associated with higher risk of early mortality.

Anatomical variations and pre-operative imaging technique concerning the anterolateral thigh flap: guiding the surgeon.

The anterolateral thigh (ALT) flap has widespread use throughout the body because of the many engineering options. The ALT has a complex local vasculature, which can be of importance for the surgical approach. In general, the flap receives its perfusion from branches of the lateral circumflex femoral artery (LCFA). The LCFA, however, has a large anatomic variance. CT angiography can guide the surgeon in the selection of the most suitable site and aid in the surgical approach.

Yttrium-90 radioembolization for the treatment of chemorefractory colorectal liver metastases: Technical results, clinical outcome and factors potentially influencing survival.

BACKGROUND: The purpose of this study was to retrospectively assess the technical and clinical outcomes, overall survival and prognostic factors for prolonged survival after yttrium-90 ((90)Y) radioembolization as a salvage therapy for patients with chemorefractory liver-only or liver-dominant colorectal metastases. MATERIAL AND METHODS: From January 2005 to January 2014, all the patients selected for (90)Y radioembolization to treat chemorefractory colorectal liver metastases were identified. Demographic, laboratory, imaging and dosimetry data were collected. Post-treatment technical and clinical outcomes were analyzed as well as overall survival; finally several factors potentially influencing survival were analyzed. RESULTS: In total 88 patients were selected for angiographic workup; 71 patients (81%) finally underwent catheter-directed (90)Y microsphere infusion into the hepatic artery 25 days (standard deviation 13 days) after angiographic workup. Median infused activity was 1809 MBq; 30-day toxicity included: fatigue (n = 39; 55%), abdominal discomfort (n = 33; 47%), nausea (n = 5; 7%), fever (n = 14; 20%), diarrhea (n = 6; 9%), liver function abnormalities and elevated bilirubin (transient) (n = 3; 4%). Gastric ulcer was found in five patients (7%). A late complication was radioembolization-induced portal hypertension (REIPH) in three patients (4%). Median time to progression in the liver was 4.4 months. Estimated survival at six and 12 months was 65% and 30%, respectively, with a 50% estimated survival after 8.0 months in this group of chemorefractory patients. Prognostic factors for worse survival were high preprocedural bilirubin, alkaline phosphatase and tumor volume levels. CONCLUSION: (90)Y microsphere radioembolization for chemorefractory colorectal liver metastases has an acceptable safety profile with a 50% estimated survival after 8.0 months. Pretreatment high bilirubin, alkaline phosphatase and tumor volume levels were associated with early death.

Mechanical endovascular thrombectomy for acute ischemic stroke: a retrospective multicenter study in Belgium.

Clinical trials have shown a beneficial effect of mechanical thrombectomy in acute ischemic stroke patients treated within six up to even 12 h after symptom onset. This treatment was already performed in selected hospitals in Belgium before completion of the randomized controlled trials. Outcome data on these procedures in Belgium have not been published. We performed a retrospective multicenter study of all patients with acute ischemic stroke treated with mechanical endovascular therapy in four hospitals in Belgium. Clinical outcomes, as measured by the modified Rankin Scale (mRS), site of arterial occlusion, reperfusion and the association between these variables were studied. The study included 80 patients: 65 patients with an occlusion in the anterior circulation and 15 with an occlusion in the posterior circulation. Good functional outcome (GFO) rates, defined as mRS 0-2 at 90 days, were 42 % in all patients, 44 % in anterior circulation stroke and 34 % in posterior circulation stroke. Reperfusion was achieved in 78 % of patients; more (100 %) in patients with posterior compared to patients with anterior circulation stroke (72 %; p = 0.02). The rate of GFO was greater in patients with reperfusion versus patients in whom reperfusion was not achieved (adjusted OR 8.2, 95 % CI 2.0-34.2). Symptomatic intracerebral hemorrhage was documented in 5 % of all patients. Endovascular treatment with mechanical devices for acute ischemic stroke in Belgium results in GFO and reperfusion rates similar to recently published results in the endovascular-treated arms of randomized clinical trials. Rates of symptomatic intracranial hemorrhage are low and comparable to other cohort studies and clinical trials.

Palliative endovascular treatment of cancer-related iliocaval obstructive disease: technical and clinical outcomes.

BACKGROUND: Cancer-related obstruction of large abdominal and pelvic veins might become symptomatic with clinical signs of lower limb venous congestion. Technical and clinical outcome after interventional treatment is not well studied yet. PURPOSE: To retrospectively assess the technical and clinical outcome of endovascular management of symptomatic cancer-related iliocaval venous obstructive disease. MATERIAL AND METHODS: From 1998 to 2013, 19 patients (15 men, 4 women; mean age, 63.6 years) referred for interventional treatment of cancer-related iliocaval obstructive disease were identified. Patients' symptoms included unilateral (n = 16; 84%) or bilateral (n = 3; 16%) painful swelling of the lower limbs. Patients' demographics as well as interventional and clinical outcome data were collected. RESULTS: All 19 patients underwent, under local anesthesia, stenting of the iliac vein (n = 16; 84%) or inferior vena cava (n = 3; 16%). Immediate technical success (n = 19) was 100%; immediate clinical success (n = 18) was 94.7%. During follow-up, seven patients (36.8%) presented with recurrent symptoms of painful limb swelling. Estimated survival after 3 and 6 months was 68.4% (95% confidence interval [CI], 47.8-82.3%) and 19.8% (95% CI, 11.9-29.2%), respectively. CONCLUSION: Endovascular stenting of cancer-related iliocaval venous obstructive disease is safe and results in immediate relief of symptoms. However, recurrent venous obstruction is common. At 3 months follow-up, the majority of patients with iliac vein stenting were still alive.

Percutaneous rheolytic thrombectomy of thrombosed autogenous dialysis fistulas: technical results, clinical outcome, and factors influencing patency.

PURPOSE: To retrospectively analyze the technical and clinical outcome of percutaneous rheolytic thrombectomy with the use of the AngioJet device in thrombosed autogenous arteriovenous dialysis fistulas. METHODS: A cohort of 38 consecutive patients (24 men; mean age 70.7 ± 13.8 years) presenting with 59 thrombotic events in 39 autogenous dialysis fistulas were retrospectively analyzed. The AngioJet rheolytic thrombectomy device was used in all cases. Adjunctive therapies, as well as procedure-related complications, were noted. Primary, assisted primary, and secondary patency of the autogenous fistulas was assessed along with factors potentially influencing patency. RESULTS: Initial technical success to recanalize the efferent vein was 100% (n = 59), and a successful postprocedure dialysis session was possible in 97% (n = 57) of cases. Adjunctive procedures included percutaneous thromboaspiration (n = 4, 7%), balloon angioplasty (n = 59, 100%), and stent placement (n = 16, 27%). Complications related to thrombectomy occurred in 3 (5%) procedures (distal arterial embolus). Primary, assisted primary, and secondary patency rates at 12 months were 56.1% (95% CI 42.8% to 75.2%), 61.6% (95% CI 48.6% to 74.7%), and 86.2% (95% CI 74.9% to 97.5%), respectively. Risk factors for early fistula occlusion were greater patient age (p = 0.045), the age of the fistula (p = 0.045), previous stent insertion (p = 0.019), and an upper arm fistula (p = 0.047). CONCLUSION: Percutaneous rheolytic thrombectomy of autogenous dialysis fistulas is effective in restoring patency and allowing subsequent hemodialysis. The complication rate is acceptably low, and the large majority of the fistulas are still used for hemodialysis at 1-year follow-up. Older fistulas and upper arm fistulas are at higher risk for early rethrombosis.