Incorporation of transradial approach in neuroendovascular procedures: defining benchmarks for rates of complications and conversion to femoral access.

BACKGROUND: The transradial approach (TRA) has gained increasing popularity for neuroendovascular procedures. However, the experience with TRA in neuroangiography is still in early stages in most centers, and the safety and feasibility of this approach have not been well established. The purpose of this study is to report the safety and feasibility of TRA for neuroendovascular procedures. METHODS: We reviewed charts from six institutions in the USA to include consecutive patients who underwent diagnostic or interventional neuroendovascular procedures through TRA from July 2018 to July 2019. Collected data included baseline characteristics, procedural variables, complications, and whether there was a crossover to transfemoral access. RESULTS: A total of 2203 patients were included in the study (age 56.1±15.2, 60.8% women). Of these, 1697 (77%) patients underwent diagnostic procedures and 506 (23%) underwent interventional procedures. Successfully completed procedures included aneurysm coiling (n=97), flow diversion (n=89), stent-assisted coiling (n=57), balloon-assisted coiling (n=19), and stroke thrombectomy (n=76). Crossover to femoral access was required in 114 (5.2%). There were no major complications related to the radial access site. Minor complications related to access site were seen in 14 (0.6%) patients. CONCLUSION: In this early stage of transforming to the 'radial-first' approach for neuroendovascular procedures, TRA was safe with low complication rates for both diagnostic and interventional procedures. A wide range of procedures were completed successfully using TRA.

Republished: Intracranial vessel occlusion preceding the development of mycotic aneurysms in patients with endocarditis.

Mycotic aneurysms (MA) are an uncommon complication of infectious endocarditis. Septic emboli are thought to be the precipitating event in their development, but the evidence for this is sparse. We present three cases in which septic embolic occlusion preceded MA development at the occlusion site, suggesting that documented angiographic emboli in patients with infectious endocarditis and bacteremia constitute a risk factor for MA formation. Two adult patients with a history of intravenous drug use and one child with congenital heart disease are described. They were all diagnosed with infectious endocarditis and developed neurological symptoms during their hospital course. Initial catheter-based cerebral angiograms demonstrated vascular occlusions, which were followed by the development of MA at the same sites within 1 month. Septic emboli, documented on cerebral angiogram, in patients with infectious endocarditis may precede the appearance of MA. Patients with angiographic occlusions in the setting of endocarditis warrant close follow-up.

Transradial versus transfemoral approaches for diagnostic cerebral angiography: a prospective, single-center, non-inferiority comparative effectiveness study.

BACKGROUND: Interventional cardiology produced level 1 evidence recommending radial artery-first for coronary angiography given lower vascular complications. Neuroendovascular surgeons have not widely adopted the transradial approach. This prospective, single center, non-inferiority comparative effectiveness study aims to compare the transradial and transfemoral approaches for diagnostic cerebral angiography with respect to efficacy, safety and patient satisfaction. METHODS: Consecutive patients presenting for diagnostic cerebral angiography were selected to undergo right radial or femoral access based on date of presentation. Primary outcome was ability to answer the predefined diagnostic goal of the cerebral angiogram using the initial access site and was assessed with a non-inferiority design. Secondary outcomes included technical success per vessel, complications, procedure times and patient satisfaction. RESULTS: A total of 312 patients were enrolled, 158 and 154 for right radial and femoral access, respectively. The diagnostic goal of the angiogram was achieved in 152 of 154 (99%) patients who underwent attempted femoral access compared with 153 of 158 (97%) patients who underwent radial access, confirming non-inferiority of the transradial approach. Secondary outcomes showed equivalent technical success by vessel, no major complications, and similar frequency of minor complications between the two approaches. In-room time was similar between approaches, though post-procedure recovery room time was significantly shorter for transradial patients. Patient satisfaction results significantly favored the radial approach. CONCLUSIONS: In patients undergoing diagnostic cerebral angiography, transfemoral and transradial access achieve procedural goals with similar effectiveness and safety, though patients strongly prefer the radial approach. Findings support consideration of adopting a radial-first strategy for diagnostic cerebral angiography.

Middle Meningeal Artery Embolization for the Treatment of an Expanding Epidural Hematoma.

INTRODUCTION: Epidural hematomas (EHs) usually originate from traumatic injury to the middle meningeal artery (MMA). Although large EHs may need to be emergently evacuated, the management of smaller EHs is less clear, especially in the absence of significant mass effect or neurologic deficits. Endovascular treatment via MMA embolization for epidural hematomas has only been recently reported. Herein, we present a case whereby MMA embolization was performed to prevent further growth of an expanding, right-sided EH after a larger left EH was surgically evacuated. CASE DESCRIPTION: A 31-year-old male patient was brought to the emergency department after he was found down by the police at his house. He was initially conversant but quickly became obtunded within a few minutes. An initial scan showed bilateral (left larger than right) acute EHs, and the patient was taken to the operating room for a left craniotomy. Immediate postoperative imaging demonstrated an expanding right-sided EH. The patient was emergently taken to the endovascular suite and obvious contrast extravasation was noticed from the parietal branch of the MMA. The MMA was embolized via a transradial approach. Follow-up imaging revealed stable hematoma size without the need for additional surgery. The patient was discharged without any neurologic deficits. CONCLUSIONS: Herein, we report the successful endovascular treatment of an expanding EH following a contralateral craniotomy. Active bleeding of the MMA was observed via angiography and may predict further EH expansion. Endovascular exploration and possible treatment can be justified in patients with EH that do not have a clear surgical indication.

Stentriever salvage after failed manual aspiration thrombectomy.

INTRODUCTION: Manual aspiration thrombectomy (MAT) and stent retriever mediated aspiration thrombectomy (SMAT) are well described reperfusion strategies for large vessel occlusions. This study aims to identify predictors of successful crossover to SMAT after failed first pass MAT. METHODS: Prospectively collected data for patients with acute large vessel occlusions undergoing thrombectomy over a 23 month period at a comprehensive stroke center were reviewed. The primary outcome was successful removal of the index clot with resultant Thrombolysis in Cerebral Infarction 2b or greater reperfusion at any point after a failed initial MAT attempt, and multivariate logistic regression analyses were performed to determine predictors of successful crossover to SMAT. RESULTS: Of 433 large vessel thrombectomies, 319 underwent first pass MAT, and 113 patients required a repeated pass for the index thrombus. Second pass MAT was performed in 77% of cases and was successful in 54%; second pass SMAT was performed in 23% of cases and was successful in 73% (P=0.11). Third pass MAT was employed in 45% of cases and was successful in 43% while SMAT was performed in 55% of cases and was successful in 77% (P=0.03). Overall, 12% of patients undergoing MAT on the first pass crossed over to successful SMAT. Predictors of successful crossover were internal carotid artery (ICA) location and higher presenting National Institutes of Health Stroke Scale (NIHSS) score. CONCLUSION: After failed first pass MAT, subsequent passes with SMAT had higher rates of successful index clot removal; patients with a higher initial NIHSS score and ICA clot location should be considered for early crossover or even initial SMAT for their clots.

Maturing institutional experience with the transradial approach for diagnostic cerebral arteriography: overcoming the learning curve.

BACKGROUND: Despite growing interest in the transradial approach for neurovascular procedures, prospective data about the learning curve for neurointerventionalists adopting this approach are limited. METHODS: A subsequent prospective series of 50 consecutive right transradial diagnostic cerebral arteriograms was compared with our initial institutional experience using a procedural staging system. The primary outcome was the ability to achieve the predefined procedural goals using the radial approach. Secondary outcomes included the technical ability to access and inject each supraaortic artery of interest and the incidence of complications. RESULTS: The primary outcome was achieved in 49 patients (98%) compared with 88% in the initial series (p=0.05). One stage 2 failure (2%) occurred. Crossover to the transfemoral approach occurred in one patient (2%) compared with 8% in the initial series (p=0.16). All supraaortic arteries of interest were accessed and injected with success rates between 93% and 100%. There were no major complications and two minor complications. CONCLUSION: Neurointerventionalists can overcome the right transradial learning curve and achieve high success rates and low crossover rates after performing 30-50 cases.

A prospective study of the transradial approach for diagnostic cerebral arteriography.

BACKGROUND: The transradial approach for cardiac catheterization is associated with improved patient safety and satisfaction in comparison with the transfemoral approach. Prospective data for the transradial approach for cerebral arteriography are lacking. OBJECTIVE: To carry out a prospective study of consecutive patients undergoing transradial cerebral arteriography at our institution to evaluate the safety, feasibility, and limitations of this approach. METHODS: Consecutive patients referred for diagnostic cerebral arteriography at an institution with minimal transradial experience were enrolled until 50 right transradial diagnostic cerebral arteriograms were obtained. A procedural staging system was developed and goals of angiography were defined before each procedure. The primary outcome was the ability to achieve the predefined goals using the transradial approach. Secondary outcomes included the technical ability to access and inject each supra-aortic artery of interest and the incidence of complications. RESULTS: A total of 65 patients were screened; 15 were excluded owing to contraindications and 50 underwent attempted right transradial cerebral arteriography. The primary outcome was achieved in 44 patients (88%). Failures occurred at stage 1 (n=3, 6%), stage 2 (n=1, 2%), stage 3a (n=1, 2%), and stage 3b (n=1, 2%). Crossover to the transfemoral approach occurred in four patients (8%) and the procedure was terminated in two patients (4%). All supra-aortic arteries of interest were accessed and injected, with success rates between 89% and 100% with the exception of the left vertebral artery (successful in 59%). There were no major complications and five minor complications. CONCLUSION: Neurointerventionalists attempting the transradial approach can expect to achieve moderate early success and a low complication rate.

Large-bore aspiration catheter selection does not influence reperfusion or outcome after manual aspiration thrombectomy.

INTRODUCTION: Various large-bore catheters can be employed for manual aspiration thrombectomy (MAT); clinical differences are rarely explored. METHODS: Prospectively collected demographic, angiographic, and clinical data for patients with acute internal carotid artery, middle cerebral artery M1, or basilar occlusions undergoing MAT over 23 months at a comprehensive stroke center were reviewed. We excluded patients in stentriever-based randomized trials/registries. The four most commonly utilized aspiration catheters were analyzed, and multivariate logistic regression analyses were performed to determine the effect of primary aspiration catheter choice on first-pass success, final reperfusion, and modified Rankin Scale (mRS) score at 90 days. RESULTS: Of 464 large vessel thrombectomies, 180 were performed via MAT on the first pass with one of four catheters. First-pass success was achieved in 42% of cases overall; this rate did not differ significantly between catheters: 50% for Sofia, 45% for CAT6, 40% for 0.072 inch Navien, and 36% for ACE68, p=0.67. Final Thrombolysis in Cerebral Infarction 2b or 3 reperfusion was achieved in 94% of cases overall: 97% of cases with CAT6, 95% with Sofia, 92% with Navien, and 92% with ACE68, p=0.70. Mean number of passes for index thrombus (2.0 overall), median procedure time (32 min overall), 90-day good outcome (mRS 0-2, mean 36%), and 90-day mortality (mean 27%) did not differ significantly between patients treated with different initial catheters. CONCLUSION: Among large-bore aspiration catheters, catheter selection is not an independent predictor of first-pass success, final reperfusion, or clinical outcome.

Intracranial vessel occlusion preceding the development of mycotic aneurysms in patients with endocarditis.

Mycotic aneurysms (MA) are an uncommon complication of infectious endocarditis. Septic emboli are thought to be the precipitating event in their development, but the evidence for this is sparse. We present three cases in which septic embolic occlusion preceded MA development at the occlusion site, suggesting that documented angiographic emboli in patients with infectious endocarditis and bacteremia constitute a risk factor for MA formation. Two adult patients with a history of intravenous drug use and one child with congenital heart disease are described. They were all diagnosed with infectious endocarditis and developed neurological symptoms during their hospital course. Initial catheter-based cerebral angiograms demonstrated vascular occlusions, which were followed by the development of MA at the same sites within 1 month. Septic emboli, documented on cerebral angiogram, in patients with infectious endocarditis may precede the appearance of MA. Patients with angiographic occlusions in the setting of endocarditis warrant close follow-up.

Seeing Is Believing: Headway27 as a Highly Visible and Versatile Microcatheter with Ideal Dimensions for Stroke Thrombectomy.

INTRODUCTION: Microcatheter selection is an infrequent focus of stroke thrombectomy technique evaluation. The Headway27 microcatheter strikes an excellent balance of microcatheter dimensions (156 cm length, 2.6 Fr distal OD, ID 0.027 inches) and visibility, making it ideal for stroke thrombectomy. METHODS: We evaluated a prospectively maintained acute stroke thrombectomy database containing 50 consecutive cases using the Headway27 microcatheter. From the database, patient demographics, clinical and angiographic information as well as procedural technical details and complications were extracted. RESULTS: Manual aspiration thrombectomy (MAT) was performed alone in 72% of cases, stentriever-assisted MAT was performed in 6% of cases, and a combination was used in 22% of cases. Median groin puncture to final recanalization time was 27 min and mTICI 2B/3 recanalization was achieved in 94% of cases. There were 2 intra-procedural complications, neither related to the microcatheter. In all cases, the Headway27 reached the intended target vessel: M1 (n = 4), M2 (n = 26), M3 (n = 13), P2 (n = 3), P3 (n = 1), and basilar artery (n = 3). There were no cases requiring usage of an additional or alternative microcatheter. In 45/47 cases of MAT, the reperfusion catheter tracked over the Headway to the clot/intended target; in two cases, the microcatheter was used to deploy a stentriever that then allowed the reperfusion catheter to track to the clot. CONCLUSION: The Headway27 microcatheter reliably facilitated rapid clot access in anterior and posterior circulation acute large vessel occlusions with no microcatheter-associated complications.

Intravenous Drug Use Is Novel Predictor of Infectious Intracranial Aneurysms in Patients with Infective Endocarditis.

INTRODUCTION: Infectious intracranial aneurysms (IIAs) are a rare but potentially devastating complication of infective endocarditis. The clinical and radiographic findings that predispose patients to IIA remain poorly understood. METHODS: We performed a retrospective review of a prospectively maintained database of consecutive endocarditis patients undergoing catheter-based angiography at a single tertiary-level academic center during the period of July 2013-December 2017. Patient records were reviewed for clinical and radiographic characteristics that may be associated with IIA. Multivariate regression models were used to evaluate the relationship between clinical and radiographic characteristics and presence of IIA on invasive imaging. RESULTS: Of 92 patients included in this analysis, 12 of them with 19 IIAs were discovered. Univariate analysis identified age, male sex, presence of hemorrhage, and history of IV drug use (IVDU) as predictors of IIA presence. After multivariate analysis, only intracranial hemorrhage and IVDU remained as independent predictors of IIA. CONCLUSIONS: Presence of hemorrhage on noninvasive imaging and history of IVDU are independently predictive of IIA presence in patients with infectious endocarditis. Risk stratification using these 2 factors may help identify the most vulnerable populations for IIA formation.

Stent Reconstruction of Carotid Tonsillar Loop Dissection Using Telescoping Peripheral Stents.

BACKGROUND: Endovascular treatment options for internal carotid artery (ICA) dissection with tandem intracranial occlusion are evolving. We report 2 cases of stent reconstruction of carotid loop dissections. METHODS: Two patients with symptomatic ICA dissections of true 360° tonsillar loops and tandem intracranial occlusions were treated with manual aspiration thrombectomy (MAT) and telescoping Zilver self-expanding peripheral stents. Patient demographics, clinical presentations, endovascular techniques, and clinical outcomes were reviewed. RESULTS: In both cases, MAT achieved modified Treatment in Cerebral Ischemia scale 2B reperfusion, and complete endovascular reconstruction of the dissected extracranial loop was performed. Both patients had improved pre- to postintervention National Institutes of Health Stroke Scale scores (16 to 0 and 14 to 0), and both had modified Rankin scale scores of 1 at 3-month follow-up. CONCLUSIONS: Stent reconstruction of complex cerebrovascular anatomy is increasingly feasible with advancements in stent technology and catheter support system design. This technique may be of use to neuroendovascular surgeons who encounter variant ICA anatomy.

Use of Omnipaque Intraoperative Dye in the Surgical Treatment of Pan-Spinal Epidural Abscesses: Technical Case Report.

BACKGROUND AND IMPORTANCE: Spinal epidural abscesses are difficult to diagnose and could have high morbidity and mortality if left untreated. If patients present with acute neurological deficits and evidence of a multilevel ventral spine abscess on neuroimaging, blood cultures should be taken and the abscess emergently evacuated in patients able to tolerate surgical interventions. CLINICAL PRESENTATION: A 57-year-old man presented with lower back pain, which progressed to include urinary retention and evidence of lumbar discitis/osteomyelitis on magnetic resonance imaging. The patient was started on antibiotic therapy. After the patient developed new cervical pain, interval magnetic resonance imaging showed extension of the abscess to involve the cervical, thoracic, and lumbar spine with intraventricular extension. The decision was made to perform a C4 corpectomy and insert a flexible ventriculoperitoneal catheter to serially flush out the abscess. Omnipaque dye was then used to ensure that the entire abscess was evacuated and no septations existed in the anterior epidural space. CONCLUSION: The patient's neurological deficits completely resolved, and he is intact a year after the operation. In selected patients with pan-spinal epidural abscesses associated with acute neurological deficits, a combination of an open approach and a catheter-based procedure in addition to an intraoperative monitoring option to ensure complete evacuation of the abscess and absence of septations in the anterior epidural space is a low-morbidity option in the armamentarium of the surgeon.