Ethical Considerations in Endovascular Thrombectomy for Stroke.

INTRODUCTION: Stroke is a leading cause of morbidity and mortality globally. Endovascular mechanical thrombectomy is considered for patients with large vessel occlusion stroke presenting up to 24 hours from onset and is being increasingly utilized across diverse clinical contexts. Proactive consideration of distinctive ethical dimensions of endovascular thrombectomy (EVT) can enable stroke care teams to deliver goal-concordant care to appropriately selected patients with stroke but have been underexplored. METHODS: A narrative review with case examples was conducted. RESULTS: We explain and critically evaluate the application of foundational bioethical principles and narrative ethics to the practice of EVT, highlight key ethical issues that may emerge in neuroendovascular practice and develop an ethical framework to aid in the responsible use of EVT for people with large-vessel occlusive ischemic stroke. CONCLUSIONS: EVT for stroke introduces important ethical considerations. Salient challenges include decision-making capacity and informed consent, the telos of EVT, uncertainty, access to care, and resource allocation. An ethical framework focusing on combining patient values and preferences with the best available evidence in the context of a multidisciplinary care team is essential to ensure that the benefits of EVT are responsibly achieved and sustained.

Deferral of Consent: Recent Lessons From Canadian Acute Stroke Trials.

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Ethical considerations in neurology during the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) pandemic has struck many countries and caused a great number of infected cases and death. Healthcare system across all countries is dealing with the increasing medical, social, and legal issues caused by the COVID-19 pandemic, and the standards of care are being altered. Admittedly, neurology units have been influenced greatly since the first days, as aggressive policies adopted by many hospitals caused eventual shut down of numerous neurologic wards. Considering these drastic alterations, traditional ethical principles have to be integrated with state-of-the-art ethical considerations. This review will consider different ethical aspects of care in neurologic patients during COVID-19 and how this challenging situation has affected standards of care in these patients.

NeuroEthics and End of Life Care.

The emergency department is where the patient and potential ethical challenges are first encountered. Patients with acute neurologic illness introduce a unique set of dilemmas related to the pressure for ultra-early prognosis in the wake of rapidly advancing treatments. Many with neurologic injury are unable to provide autonomous consent, further complicating the picture, potentially asking uncertain surrogates to make quick decisions that may result in significant disability. The emergency department physician must take these ethical quandaries into account to provide standard of care treatment.

A randomized pragmatic care trial on endovascular acute stroke interventions (EASI): criticisms, responses, and ethics of integrating research and clinical care.

BACKGROUND: The Endovascular Acute Stroke Intervention (EASI) trial was conceived as a pragmatic care trial, designed to integrate trial methods with clinical practice. Reporting the EASI experience was met with objections and criticisms during peer review concerning both scientific and ethical issues. Our goal is to discuss these criticisms in order to promote the pragmatic approach of care trials in outcome-based medical care. METHODS: The comments and criticisms of 11 reviewers from 5 journals were collected and analyzed. The EASI protocol was also compared to the protocols of seven thrombectomy trials using the pragmatic-explanatory continuum indicator summary (PRECIS). RESULTS: Main criticisms of EASI concerned selection criteria that were judged to be too vague and too inclusive, brain and vascular imaging methods that were not sufficiently prescribed by protocol, lack of blinding of outcome assessment, and lack of power. EASI was at the pragmatic end of the spectrum of thrombectomy trials. CONCLUSION: The pragmatic care trial methodology is not currently well-established. More work needs to be done to integrate scientific methods and ethical care in the best medical interest of current patients.

El aneurisma de aorta abdominal / The abdominal aortic aneurysm

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Is medical advertising always unethical, or does it just seem to be?

Dr C. Lever is the undisputed expert in a new endovascular procedure he developed and brought to fruition over the years. Other professionals publishing their results call it by his name, although he has strictly avoided that nomenclature. Lever is at a medical center with several participating hospitals, which boast aggressive ultracompetitive marketing departments. His hospital wants to concentrate on him as proof that the best care is available at their facility. A successful campaign certainly would add to Lever's and perhaps to his group's referrals. He looks at the first advertisement and a Greek god would have been less vaunted but nothing said is untrue. What should he do? A. Ask that all advertising identifying him be discontinued immediately. B.Tell them to hype it up. C. Ask that marketing stick to the facts completely sans hype. D. Check with the Ethics Committee of the hospital. E. Check with the Ethics Committee of the American Medical Association (AMA) or American College of Surgeons or the appropriate surgical subspecialty professional association.

La paternidad del Endovascular aneurysm/aortic repair. Las primeras descripciones fueron en español / The paternity of Endovascular aneurysm/aortic repair: The first descriptions were in Spanish

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¿Existe algún factor de riesgo predictivo de mortalidad a corto plazo en pacientes de alto riesgo intervenidos de aneurismas de aorta abdominal mediante endoprótesis? / Is there any predictive risk factor of short-term mortality in high risk patients operated on for aortic abdominal aneurysms using endoprosthesis?

OBJETIVOS: Identificar factores predictivos de mortalidad a corto plazo (<24 meses) en pacientes con aneurisma de aorta abdominal (AAA), de alto riesgo quirúrgico, tratados mediante endoprótesis. MATERIAL Y MÉTODOS: Estudio retrospectivo mediante revisión de historias clínicas entre enero de 2006 y junio de 2010. El seguimiento medio de los pacientes fue de 23,7 meses (DE = 16,3; rango: 0-62). Se compara el grupo de mortalidad a corto plazo (<24 meses) con el resto, mediante regresión logística multivariante. RESULTADOS: El 3,5% (2 casos) falleció durante el ingreso y el 30,9% (17 casos) durante el periodo de seguimiento. La media de supervivencia fue 41,1 meses (34-48,2; mediana = 40 meses). La mortalidad antes de 24 meses fue el 21% (12 pacientes). En el análisis multivariante se encontró que el único factor predictivo de mortalidad a corto plazo fue la presencia de enfermedad pulmonar obstructiva crónica (EPOC) (p = 0,014; OR 13,7; IC = 1,7-109). CONCLUSIONES: La EPOC en pacientes de alto riesgo quirúrgico parece ser indicativa de mortalidad a corto plazo

OBJECTIVES: To detect any risk factor of short-term mortality in high risk patients undergoing endovascular abdominal aortic aneurism (EVAR) repair. MATERIAL AND METHODS: A retrospective study was conducted from January 2006 to June 2010, with a mean follow-up of 23.7 months. A multiple logistic regression model was used to evaluate variables of mortality after EVAR in early mortality patients. RESULTS: Two (3.5%) cases died during hospital admission, and 30.9% during the follow-up period. Short-term mortality rate (before 24 months) was 21% (12 patients). chronic obstructive pulmonary disease (COPD) was the only significant predictor of short-term mortality (P=.014; OR 13.7; 95% CI = 1.7-109). CONCLUSIONS: COPD in high risk patients could predict short-term mortality after EVAR

Disección de aorta tipo B no complicada: ¿debe ser todavía el tratamiento médico la mejor opción? Sí, el tratamiento conservador es la mejor opción / Uncomplicated type B aortic dissection: Must medical treatment still be the best option? Yes, conservative treatment is the best option

La disección aguda tipo B es una de las más temibles enfermedades que pueden acontecer en la aorta. Clásicamente, el tratamiento recomendado ha sido conservador, encaminado sobre todo a un correcto control de la tensión arterial y el dolor. Sin embargo, el advenimiento de la terapia endovascular y su aplicación satisfactoria en disecciones aórticas complicadas (pacientes con inestabilidad hemodinámica, isquemia periférica, malperfusión visceral o rotura contenida) ha expandido su empleo en todos los casos. Este hecho ha suscitado una importante controversia en relación con el tratamiento adecuado de esta dolencia, especialmente en aquellas disecciones no complicadas. Hasta el momento actual, el tratamiento endovascular parece que se asocia a un mayor grado de trombosis de la luz falsa y una remodelación más favorable de la aorta durante su seguimiento, pero faltan datos que demuestren que esa actitud mejora la supervivencia global de los pacientes. Los autores de estos artículos analizan la eficacia de la terapia endovascular en disecciones no complicadas de la aorta descendente, revisando las últimas evidencias a favor y en contra de su empleo

Acute type-B dissection is one of the most dreaded diseases that can occur in the aorta. Classically, the preferred medical treatment has been the perfect control of the blood pressure and the pain. However, the advent of endovascular therapy and its successful implementation in complicated aortic dissections (patients with hemodynamic instability, peripheral ischemia, visceral malperfusion or contained rupture) has expanded its use in all cases. This has led to considerable controversy regarding the appropriate treatment of this disease, especially in uncomplicated aortic dissections. To date, endovascular therapy appears to cause more thrombosis of the false lumen and a more favorable remodeling of the aorta during the followup, but missing data shows that this approach improves the overall survival of these patients. The authors of these articles analyze the effectiveness of endovascular therapy in uncomplicated dissections of the descending aorta, reviewing the latest evidence for and against its use

Tratamiento endovascular del divertículo de Kommerell / Endovascular treatment of Kommerell's diverticulum

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Nikolay L. Volodos. Un pionero del EVAR / Nikolay L. Volodos. A pioneer of EVAR

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¿Es la carga de trombo y su localización en el saco un factor protector de endofugas tipo II? / Is thrombus load and location a protection factor of type II endoleaks?

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A guide to multi-centre ethics for surgical research in Australia and New Zealand.

BACKGROUND: This paper describes existing inconsistencies as well as the disparate processes and logistics required when obtaining ethics approval in Australia and New Zealand in order to initiate a multi-centre bi-national surgical trial. METHODS: The endovascular aortic aneurysm repair trial is a large multi-centre trial that aims to obtain pre- and post-operative data from patients in hospitals across Australia and New Zealand. As the trial was research based, ethics applications were submitted to all hospitals where surgeons wished to be involved in the trial. RESULTS: Few ethics committees have embraced attempts to simplify the application process for multi-centre trials. There was limited mutual review between Human Research Ethics Committees necessitating the submission of multiple applications. Though the use of the National Ethics Application Form in ethical review is increasing, some Human Research Ethics Committees do not accept it in its entirety; many require site-specific applications or sections of the Common Application Form modules. CONCLUSIONS: Queensland, New South Wales and New Zealand were the easiest systems to prepare, submit and lodge ethics applications because of their understanding and accommodation of reviewing multi-centred trials. The time, expense and complexity of obtaining ethics approval for multi-centre research projects are impediments to their establishment and reduce the time available for research. Australia is working to implement a system named the Harmonisation of Multi-centre Ethical Review to ease the process of obtaining multi-centre ethics clearance. Our experience suggests there will be some teething problems with implementation and acceptance.