The 10-year trend of periprocedural complication following carotid artery stenting; single center experience.

PURPOSE: Carotid endarterectomy and stenting are used to treat carotid stenosis, with the volume of carotid artery procedures increasing over the past decade. We investigated the 10-year trend of periprocedural complications with an increasing procedure volume of carotid stenting at a single tertiary hospital. METHODS: We collected 416 consecutive cases (384 patients) of carotid artery stenting performed for either symptomatic (231 cases, 55.5 %) or asymptomatic (185 cases, 44.5 %) internal carotid artery stenosis at a single center. Periprocedural complication was defined as any stroke, myocardial infarction, or death. Procedure-related outcome included any dissection, hemodynamic event, or periprocedural complication. RESULTS: The mean age was 68.8 years (82.8 % males; range of 20-89 years); 23.9 % were older than 75 years. Before the procedure, 99.3 and 56.0 % of patients received antiplatelet and lipid-lowering medication, respectively. The overall periprocedural complication rate was 3.6 % (1.6 and 5.2 % in the asymptomatic and symptomatic group, respectively). The composite outcome of any stroke or death was 3.4 %. Periprocedural complication and procedure-related outcome showed a decremental trend with increasing procedure volume, and this trend remained after adjusting for confounders. CONCLUSIONS: Our study suggests that carotid stenting at an experienced center might reduce the periprocedural complications. Our periprocedural complication rate of carotid artery stenting may be comparable to, or somewhat lower than, that reported in other clinical trials.

Extracorporeal membrane oxygenation for acute life-threatening neurogenic pulmonary edema following rupture of an intracranial aneurysm.

Neurogenic pulmonary edema (NPE) leading to cardiopulmonary dysfunction is a potentially life-threatening complication in patients with central nervous system lesions. This case report describes a 28-yr woman with life-threatening fulminant NPE, which was refractory to conventional respiratory treatment, following the rupture of an aneurysm. She was treated successfully with extracorporeal membrane oxygenation (ECMO), although ECMO therapy is generally contraindicated in neurological injuries such as brain trauma and diseases that are likely to require surgical intervention. The success of this treatment suggests that ECMO therapy should not be withheld from patients with life-threatening fulminant NPE after subarachnoid hemorrhage.

Intra-arterial thrombolysis using double devices: mechanicomechanical or chemicomechanical techniques.

OBJECTIVE: To optimize the recanalization of acute cerebral stroke that were not effectively resolved by conventional intraarterial thrombolysis (IAT), we designed a double device technique to allow for rapid and effective reopening. In this article, we describe the feasibility and efficacy of this technique. METHODS: From January 2008 to September 2009, twenty patients with acute cerebral arterial occlusion (middle cerebral artery : n=12; internal carotid artery terminus : n=5; basilar artery : n=3) were treated by the double device technique. This technique was applied when conventional thrombolytic methods using drug, microwires, microcatheters and balloons did not result in recanalization. In the double device technique, two devices are simultaneously placed at the lesion (for example, one microcatheter and one balloon or two microcatheters). Chemicomechanical or mechanicomechanical thrombolysis was performed simultaneously using various combinations of two devices. Recanalization rates, procedural time, complications, and clinical outcomes were analyzed. RESULTS: The initial median National Institute of Health Stroke Scale (NIHSS) was 16 (range 5-26). The double device technique was applied after conventional IAT methods failed. Recanalization was achieved in 18 patients (90%). Among them, 55% (11 cases) were complete (thrombolysis in cerebral infarction 2B, 3). The median thrombolytic procedural time including the conventional technique was 135±83.7 minutes (range 75-427). Major symptomatic hemorrhages (neurological deterioration ≥4 points in NIHSS) developed in two patients (10%). Good long term outcomes (modified Rankin Scale ≤2 at 90 days) occurred in 25% (n=5) of the cases. Mortality within 90 days developed in two cases (10%). CONCLUSION: The double device technique is a feasible and effective technical option for large vessel occlusion refractory to conventional thrombolysis.

A retrieval thrombectomy technique with the Solitaire stent in a large cerebral artery occlusion.

BACKGROUND: To describe preliminary experiences and the procedural details of retrieval thrombectomy using a self-expanding and fully retrievable Solitaire stent (ev 3 Inc., CA, USA) in acute ischemic stroke (AIS) patients with large artery occlusions. METHODS: Eight patients with AIS were treated by mechanical thrombectomy using a self-expanding, fully retrievable stent (Solitaire, ev 3 Inc., CA, USA). The stent was deployed to cover the whole intra-arterial clot and then it was slowly retrieved while occluding the internal cerebral artery (ICA) with a balloon guiding catheter. Additionally, continuous negative pressure was applied through the balloon guiding catheter with a specially designed gun device. Occlusion sites were M1 in six cases including one combined supraclinoid ICA occlusion and the other combined M2 occlusion, M2 in 1 case and one basilar artery top. RESULTS: Complete recanalization was achieved in all patients. Procedure time was 45 min or less in seven cases and 70 min in one case. Distal emboli occurred in one case in which the balloon guide catheter was not used. Only in this case was intraarterial fibrinolytics infusion necessary. There was no post-operative intracranial hemorrhage. CONCLUSIONS: In our experience, retrieval thrombectomy with the Solitaire stent was a simple and effective method for reopening large cerebral arteries in AIS patients.

Partial recovery after intraarterial pharmacomechanical thrombolysis in ophthalmic artery occlusion following nasal autologous fat injection.

Although autologous fat injection into the face is a widely used procedure in aesthetic surgery, heed must be taken because it may cause severe complications related to inadvertent arterial embolization, including stroke and vision loss. Vision loss may originate from ophthalmic artery occlusion, and no therapeutic options have yet been reported for this condition. Herein, the authors report a case of ophthalmic artery occlusion following nasal autologous fat injection. Partial recovery of choroidal and retinal perfusion, ocular motility, and corneal clarity was achieved after intraarterial pharmacomechanical thrombolysis.

Reversal of ischemic retinopathy following balloon angioplasty of a stenotic ophthalmic artery.

A 65-year-old woman who had undergone internal carotid artery stenting and was being maintained on antiplatelet therapy developed features suggesting ipsilateral reduced retinal artery perfusion. Injection of urokinase into the ophthalmic artery provided temporary improvement. When manifestations of retinal arterial ischemia recurred, angiography revealed worsening stenosis at the origin of the ophthalmic artery. Balloon angioplasty at that site successfully restored visual acuity and reversed the ischemic fundus abnormalities. This is the first report of ophthalmic artery balloon angioplasty in this setting.