Analysis of Complications Related to Endovascular Therapy for Dural Arteriovenous Fistulae

In this paper, we reviewed our cases of dural arteriovenous fistulae (dural AVFs) and analyzed periprocedural complications. In 157 procedures, we encountered 14 complications. Overall, complication rate of 9% was seen. We divided these complications into five subgroups such as cranial nerve palsy, coil-related trouble, thromboembolic complication, vessel perforation, and radiation-related trouble. There were five transient abducent nerve palsies in cases with cavernous sinus dural AVFs. There were two cases of coil unraveling and two cases of coil migration. In two cases, direct puncture of the internal jugular vein was performed to retrieve the unraveled coil by using dual microcatheter and guidewire snare technique. We encountered two thromboembolic complications. In one case, venous infarction was recognized after polyvinyl alcohol particle embolization. In two cases of vessel perforations, there were no new neurological deficits except one case with transient Gerstmann syndrome. In endovascular treatment of dural AVF, serious complications are rare and can be prevented if maximum attention is paid during the procedure.

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Triple-Catheter Technique in the Transvenous Coil Embolization of an Isolated Sinus Dural Arteriovenous Fistula

Operative Neurosurgery ◽

10.1227/01.neu.0000289718.03050.81 ◽

2007 ◽

Vol 61 (suppl_3) ◽

pp. ONS-81-ONS-85 ◽

Cited By ~ 3

Author(s):

Kenji Sugiu ◽

Koji Tokunaga ◽

Ayumi Nishida ◽

Wataru Sasahara ◽

Kyoichi Watanabe ◽

...

Keyword(s):

Coil Embolization ◽

Dural Arteriovenous Fistula ◽

Jugular Vein ◽

Sigmoid Sinus ◽

Neurological Deficits ◽

Arteriovenous Fistulae ◽

The Third ◽

Percutaneous Catheter ◽

Catheter Technique ◽

Guiding Catheter

Abstract Objective: Dural arteriovenous fistulae involving the transverse-sigmoid sinus, which is occluded at its proximal and distal ends (i.e., an isolated sinus), carry a high risk of intracranial hemorrhage or progressive neurological deficits. Although transvenous coil embolization is a useful and safe treatment for such lesions, it is often difficult to reach into the isolated sinus through the occluded sinus using the percutaneous catheter approach. Methods: We report the successful treatment of two patients with transverse-sigmoid dural arteriovenous fistulae with isolated sinus using the percutaneous transvenous triple-catheter technique. A 6-French guiding catheter was placed at the internal jugular vein followed by a second 4-French catheter positioned at the end of the occluded sinus. A third microcatheter was then navigated into the isolated sinus with support of the second catheter. Results: Although initial attempts to reach into the isolated sinus without the second catheter failed, insertion of the second catheter resulted in successful navigation of the third microcatheter into the affected sinus in both cases. Complete cure was obtained in both cases by coil packing of the affected sinus. Conclusion: Although careful maneuvering is required, this triple-catheter technique is useful for treatment of dural arteriovenous fistulae with isolated sinus.

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Management and outcomes of isolated interhemispheric subdural hematomas associated with falx syndrome

Journal of Neurosurgery ◽

10.3171/2018.8.jns181812 ◽

2019 ◽

Vol 131 (6) ◽

pp. 1920-1925

Author(s):

Daniel A. Tonetti ◽

William J. Ares ◽

David O. Okonkwo ◽

Paul A. Gardner

Keyword(s):

Neurological Deterioration ◽

Neurological Deficits ◽

Motor Deficits ◽

Study Cohort ◽

Venous Infarction ◽

Nonsurgical Management ◽

Subdural Hematomas ◽

Poor Outcomes ◽

Contemporary Management

OBJECTIVELarge interhemispheric subdural hematomas (iSDHs) causing falx syndrome are rare; therefore, a paucity of data exists regarding the outcomes of contemporary management of iSDH. There is a general consensus among neurosurgeons that large iSDHs with neurological deficits represent a particular treatment challenge with generally poor outcomes. Thus, radiological and clinical outcomes of surgical and nonsurgical management for iSDH bear further study, which is the aim of this report.METHODSA prospectively collected, single-institution trauma database was searched for patients with isolated traumatic iSDH causing falx syndrome in the period from January 2008 to January 2018. Information on demographic and radiological characteristics, serial neurological examinations, clinical and radiological outcomes, and posttreatment complications was collected and tallied. The authors subsequently dichotomized patients by management strategy to evaluate clinical outcome and 30-day survival.RESULTSTwenty-five patients (0.4% of those with intracranial injuries, 0.05% of those with trauma) with iSDH and falx syndrome represented the study cohort. The average age was 73.4 years, and most patients (23 [92%] of 25) were taking anticoagulants or antiplatelet medications. Six patients were managed nonoperatively, and 19 patients underwent craniotomy for iSDH evacuation; of the latter patients, 17 (89.5%) had improvement in or resolution of motor deficits postoperatively. There were no instances of venous infarction, reaccumulation, or infection after evacuation. In total, 9 (36%) of the 25 patients died within 30 days, including 6 (32%) of the 19 who had undergone craniotomy and 3 (50%) of the 6 who had been managed nonoperatively. Patients who died within 30 days were significantly more likely to experience in-hospital neurological deterioration prior to surgery (83% vs 15%, p = 0.0095) and to be comatose prior to surgery (100% vs 23%, p = 0.0031). The median modified Rankin Scale score of surgical patients who survived hospitalization (13 patients) was 1 at a mean follow-up of 22.1 months.CONCLUSIONSiSDHs associated with falx syndrome can be evacuated safely and effectively, and prompt surgical evacuation prior to neurological deterioration can improve outcomes. In this study, craniotomy for iSDH evacuation proved to be a low-risk strategy that was associated with generally good outcomes, though appropriately selected patients may fare well without evacuation.

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Thromboembolic Complications of Elective Coil Embolization of Unruptured Aneurysms

Neurosurgery ◽

10.1227/01.neu.0000374770.09140.fb ◽

2010 ◽

Vol 67 (3) ◽

pp. 743-748 ◽

Cited By ~ 64

Author(s):

Gyojun Hwang ◽

Chulkyu Jung ◽

Sukh Que Park ◽

Hyun Sung Kang ◽

Sang Hyung Lee ◽

...

Keyword(s):

Complication Rate ◽

Coil Embolization ◽

Single Agent ◽

Thromboembolic Complication ◽

Thromboembolic Complications ◽

Unruptured Aneurysms ◽

Complication Risk ◽

Group 2 ◽

Risk Of Hemorrhage ◽

Group 1

Abstract OBJECTIVE We retrospectively evaluated whether antiplatelet preparation lowered the thromboembolic complication rate during the perioperative period. METHODS We reviewed 328 elective coil embolization procedures in which only microcatheters were used for coiling. No antiplatelet medication was prescribed before the procedure in 95 cases (29%, group 1), whereas antiplatelet therapy was used in 233 cases (71%, group 2; 61 [18.6%] with a single agent [aspirin or clopidogrel] and 172 [52.4%] with both agents). Antiplatelet agents were not given after coiling unless atherosclerosis, severe coil protrusion, or a thromboembolic complication occurred during the procedure. A thromboembolic complication was defined as a procedural thromboembolic event or transient ischemic attack or stroke occurring within 2 days of embolization. RESULTS Thromboembolic complications occurred in 11 cases (3.4%): 6 (6.3%) in group 1 and 5 (2.1%) in group 2 (P = .085). In 195 cases (59.5%) treated by the single microcatheter technique, the risk of thromboembolic complications was low and not affected by antiplatelet preparation (1.8% [no preparation] vs 2.2% [preparation]; P = 1.000). However, in 133 cases (40.5%) treated by the multiple microcatheter technique, antiplatelet preparation significantly reduced the thromboembolic complication risk by 85.2% (12.8% [no preparation] vs 2.1% [preparation]; odds ratio, 0.148; 95% confidence interval, 0.027–0.798; P = .023). The aneurysms treated by the multiple microcatheter technique had more complex configurations for coiling (P < .001). The risk of hemorrhage was not increased by antiplatelet preparation (P = .171). CONCLUSION Antiplatelet preparation lowered the periprocedural thromboembolic complication rate in unruptured aneurysms treated by the multiple microcatheter technique and did not increase the risk of hemorrhage. Therefore, antiplatelet preparation can help to reduce complications in patients in whom technical difficulties are expected without the risk of hemorrhage.

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Platelet Function Testing in Neurovascular Procedures: Tool or Gimmick?

Interventional Neurology ◽

10.1159/000496702 ◽

2019 ◽

Vol 8 (2-6) ◽

pp. 123-134 ◽

Cited By ~ 4

Author(s):

Nicholas K. Cheung ◽

Michael W. Carr ◽

Udayan Ray ◽

Duncan McKenzie ◽

Jens J. Froelich

Keyword(s):

Platelet Function ◽

Platelet Inhibition ◽

Thromboembolic Complication ◽

Individual Variability ◽

Neurological Deficits ◽

Complication Rates ◽

Platelet Inhibitors ◽

Clinical Tool ◽

Clopidogrel Resistance ◽

Neurological Outcomes

Background: Platelet inhibitors are used to prevent thromboembolic complications related to neurovascular stenting (NVS) procedures. Despite substantial inter-individual variability of functional platelet inhibition, the value of platelet function tests (PFT) to assess inhibition remains controversial. Objective: This study was conducted to compare differences in thromboembolic complication rates associated with NVS in platelet-inhibited patients with and without PFT. Clinical neurological outcomes were assessed by differences in the modified Rankin Scale (mRS). Materials and Methods: One hundred seventeen consecutive patients underwent elective NVS procedures within a 7-year period. All patients received aspirin and clopidogrel 8 days before the procedure. Fifty-two patients were treated without assessment of platelet inhibition, and 65 patients were tested for clopidogrel resistance. When clopidogrel resistance was revealed, corresponding patients were converted to ticagrelor. Changes in mRS and thromboembolic event rates were compared between the 2 cohorts. Results: Thirty-five percent of patients from the cohort subjected to PFT tests showed inadequate platelet inhibition under clopidogrel and were converted to ticagrelor. Compared to the non-PFT test cohort, neurological deficits were significantly reduced (12 vs. 0%; p = 0.009) and a lower number of thromboembolic events was found (12 vs. 3%; p > 0.05) within the test cohort. Conclusion: PFT appears to identify patients with clopidogrel resistance prior to NVS procedures. When non-responders are converted to alternative platelet inhibitors, neurological outcomes and thromboembolic complication rates may improve. Consequently, this study provides preliminary evidence that PFT may be a useful clinical tool to enhance procedural safety and improve clinical outcomes in NVS procedures.

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Safety of prothrombin complex concentrates for rapid anticoagulation reversal of vitamin K antagonists

Thrombosis and Haemostasis ◽

10.1160/th11-01-0052 ◽

2011 ◽

Vol 106 (09) ◽

pp. 429-438 ◽

Cited By ~ 199

Author(s):

Chiara Marchesi ◽

Matteo Pierfranceschi ◽

Mark Crowther ◽

David Garcia ◽

Elaine Hylek ◽

...

Keyword(s):

Mortality Rate ◽

Vitamin K ◽

Meta Analysis ◽

Vitamin K Antagonists ◽

Total Mortality ◽

Thromboembolic Complication ◽

Thromboembolic Complications ◽

Weighted Mean ◽

Prothrombin Complex Concentrates ◽

Anticoagulation Reversal

SummaryProthrombin complex concentrates (PCCs) are recommended as the treatment of choice in warfarin-related coagulopathy. However, the risk of thromboembolic complications associated with their use is not well defined. We performed a meta-analysis to estimate the rate of thromboembolic complications in patients receiving vitamin K antagonists (VKAs) treated with PCCs for bleeding or before urgent surgery. Medline and Embase databases were searched. Two reviewers performed study selection and extracted data independently. Studies providing data on incidence of thromboembolic complications in VKA-treated patients were eligible for the study. Weighted mean proportion of the rate of thromboembolic complications and the mortality rate were calculated. Twenty-seven studies (1,032 patients) were included. Seven studies used 3-factor, and 20 4-factor PCCs. Twelve patients had a thromboembolic complication (weighted mean 1.4%; 95% CI 0.8–2.1), of which two were fatal. The incidence of thromboembolic events was 1.8% (95% CI 1.0–3.0) in patients treated with 4-factor PCCs, and 0.7% (95% CI 0.0–2.4) in patients treated with 3-factor PCCs. Total mortality rate was 10.6% (95% CI 5.9–16.6). In conclusion, our results suggest there is a low but quantifiable risk of thromboembolism in VKA-treated patients receiving PCCs for anticoagulation reversal. These findings should be confirmed in randomised, controlled trials.

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Direct-Puncture Embolization of Scalp Arteriovenous Fistulae

Neurologia medico-chirurgica ◽

10.2176/nmc.52.525 ◽

2012 ◽

Vol 52 (7) ◽

pp. 525-528 ◽

Cited By ~ 6

Author(s):

Sung Won YOUN ◽

Nam Joon LEE ◽

Sang Il SUH ◽

Sin Hyuk KANG

Keyword(s):

Arteriovenous Fistulae ◽

Direct Puncture

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The incidence of heparin-induced thrombocytopenia in hospitalized medical patients treated with subcutaneous unfractionated heparin: a prospective cohort study

Blood ◽

10.1182/blood-2002-07-2201 ◽

2003 ◽

Vol 101 (8) ◽

pp. 2955-2959 ◽

Cited By ~ 194

Author(s):

Bruno Girolami ◽

Paolo Prandoni ◽

Piero M. Stefani ◽

Cinzia Tanduo ◽

Paola Sabbion ◽

...

Keyword(s):

Platelet Count ◽

Unfractionated Heparin ◽

Odds Ratio ◽

Thromboembolic Complication ◽

High Rate ◽

Clinical Settings ◽

Medical Patients ◽

Thromboembolic Complications ◽

Heparin Induced Thrombocytopenia ◽

Medical Wards

Abstract Although heparin-induced thrombocytopenia (HIT) is a known complication of intravenous unfractionated heparin (UFH), its incidence in medical patients treated with subcutaneous UFH is less well defined. To determine the incidence of HIT in this category of patients, the platelet count was performed at baseline and then every 3 ± 1 days in 598 consecutive patients admitted to 2 medical wards and treated with subcutaneous UFH for prophylactic (n = 360) or therapeutic (n = 238) indications. The diagnosis of HIT was accepted in the case of a platelet drop of 50% or more and either the demonstration of heparin-dependent antibodies or (when this search could not be performed) the combination of the following features: (1) the absence of any other obvious clinical explanation for thrombocytopenia, (2) the occurrence of thrombocytopenia at least 5 days after heparin start, and (3) either the normalization of the platelet count within 10 days after heparin discontinuation or the earlier patient's death due to an unexpected thromboembolic complication. HIT developed in 5 patients (0.8%; 95% CI, 0.1%-1.6%); all of them belonged to the subgroup of patients who received heparin for prophylactic indications. The prevalence of thromboembolic complications in patients with HIT (60%) was remarkably higher than that observed in the remaining 593 patients (3.5%), leading to an odds ratio of 40.8 (95% CI, 5.2-162.8). Although the frequency of HIT in hospitalized medical patients treated with subcutaneous heparin is lower than that observed in other clinical settings, this complication is associated with a similarly high rate of thromboembolic events.

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Predictive value of thromboembolic complications in infective endocarditis, the possibility of prevention.

Clinical Medicine (Russian Journal) ◽

10.18821/0023-2149-2018-96-2-129-136 ◽

2018 ◽

Vol 96 (2) ◽

pp. 129-136

Author(s):

M. V. Taranova ◽

T. V. Androsova ◽

L. V. Kozlovskaya ◽

L. A. Strizhakov ◽

M. V. Lebedeva ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Ischemic Stroke ◽

Surgical Treatment ◽

Infective Endocarditis ◽

Heart Attack ◽

Thromboembolic Complication ◽

Thromboembolic Complications ◽

Intracranial Hemorrhages ◽

Treatment And Prevention ◽

The Brain

Thromboembolic syndrome is a formidable complication of infectious endocarditis (IE), which significantly worsens the prognosis. Data of literature and own results of studying of this problem are given. Among 64 patients of IE, who were under the supervision of the authors, thromboembolic syndrome was observed in 23 (36%; according to the literature - in 33-50%), including recurrent in 6. The main causative agent of the disease in this group was Staphylococcus aureus (42%), which is consistent with the data of the majority of authors, in the presence of large mobile vegetation with localization on the mitral valve, among patients without embolic events - Streptococcus viridans (47%) in the presence of smaller vegetation mainly on the aortic valve. The most dangerous thromboembolic complication was ischemic stroke in 8 (12.5%) patients, but embolic heart attack of the brain and myocardium is not always diagnosed in patients due to atypical course. The basis for the treatment and prevention of complications of IE, including thromboembolism, is early initiated adequate antibiotic therapy; at the same time, the principles of antithrombotic therapy in IE developed less. Given the high risk of intracranial hemorrhages, the decision to conduct thrombolytic therapy should be made individually by the so-called endocarditis team. The article discusses the indications for urgent surgical treatment to prevent thromboembolism.

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APC-resistance Is a Risk Factor for Postoperative Thromboembolism in Elective Replacement of the Hip or Knee – A Prospective Study

Thrombosis and Haemostasis ◽

10.1055/s-0037-1614410 ◽

1999 ◽

Vol 81 (01) ◽

pp. 18-21 ◽

Cited By ~ 48

Author(s):

Tom Lundahl ◽

Lennart Nilsson ◽

Christer Andersson ◽

Tomas Lindahl

Keyword(s):

Risk Factor ◽

Venous Thrombosis ◽

Anticoagulant Activity ◽

Activated Protein C ◽

Thromboembolic Complication ◽

Thromboembolic Complications ◽

Pulmonary Scintigraphy ◽

Apc Resistance ◽

Venous Thromboembolic ◽

A Prospective Study

SummaryPostoperative venous thromboembolic complications are commonly seen after total replacement of the hip or knee. Recently, an inherited defect with resistance to the anticoagulant activity of activated protein C (APC-resistance) has been detected. APC-resistance seems to be a common risk factor, especially in Sweden, and it increases the propensity for venous thrombosis. This study assesses the prevalence of APC-resistance in a general population and its clinical significance for patients undergoing surgery associated with a high risk of thromboembolic complications. In a prospective cohort study, we analysed for APC-resistance in 645 consecutive patients before elective replacement of the hip or knee at 3 hospitals in southern Sweden. Thromboprophylaxis with LMWH-heparin was given to all patients throughout the hospitalisation period. We recorded events of clinical thromboembolism for 3 months postoperatively. Venography, ultrasonography or pulmonary scintigraphy was requested by the clinicians according to the existing routines, i.e. only patients with symptoms of thromboembolism were examined. A thromboembolic complication was registered in 20 (3.1%) patients. Fifty per cent of the venous thrombi had a proximal location. Only 0.3% of the patients had verified pulmonary embolism. APC-resistance was found in 14.1% of the patients, of whom 9.9% had experienced postoperative thromboembolism compared with 2.0% of the patients without APC-resistance (p <0.0007). We conclude that APC-resistance is a frequent risk factor for symptomatic postoperative deep venous thrombosis with an estimated relative risk of 5.0 (95% confidence interval: from 1.9 to 12.9) in elective replacement of the hip or knee.

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Management of Intraprocedural Arterial Thrombus in Cerebral Aneurysm Embolization with Abciximab: Technical Case Report

Neurosurgery ◽

10.1097/00006123-200204000-00045 ◽

2002 ◽

Vol 50 (4) ◽

pp. 899-902 ◽

Cited By ~ 31

Author(s):

Michael J. Alexander ◽

Gary R. Duckwiler ◽

Y. Pierre Gobin ◽

Fernando Viñuela

Keyword(s):

Cerebral Aneurysm ◽

Coil Embolization ◽

Artery Aneurysm ◽

Neurological Deficits ◽

Anterior Communicating Artery ◽

Thromboembolic Complications ◽

Anterior Communicating Artery Aneurysm ◽

Guglielmi Detachable Coil ◽

Aneurysm Embolization ◽

Arterial Thrombus

Abstract OBJECTIVE AND IMPORTANCE: Thromboembolic complications after cerebral aneurysm treatment with Guglielmi detachable coils (Boston Scientific/Target, Fremont, CA) are not infrequent; in a University of California, Los Angeles institutional review of 720 treated aneurysms, thromboembolic complications occurred in 2.5% of cases. The development of intraluminal thrombus during the embolization procedure, however, may be diagnosed promptly and treated effectively with appropriate therapy. This report describes the use of intravenously administered abciximab for the treatment of intraprocedural arterial thrombus encountered during the coil embolization of a recently ruptured anterior communicating artery aneurysm. CLINICAL PRESENTATION: A 45-year-old man presented with severe headache 12 days before transfer to our institution. He had no neurological deficits at admission. Previous computed tomography of the brain demonstrated subarachnoid hemorrhage, and magnetic resonance angiography from the other institution demonstrated a 4-mm anterior communicating artery aneurysm. INTERVENTION: The patient underwent Guglielmi detachable coil embolization of the aneurysm under systemic heparinization. During the embolization, however, a thrombus developed in the proximal left A2 segment. The patient was given an intravenous infusion (20 mg) of abciximab for 10 minutes, and within 15 minutes dissolution of the thrombus was observed with no angiographic evidence of distal emboli. After reversal of general anesthesia, the patient exhibited minimal right leg weakness, which resolved within 1 hour. CONCLUSION: Abciximab may be a useful adjunct for endovascular treatment of patients with cerebral aneurysms in whom intraprocedural arterial thrombus is encountered.

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