Chemical Angioplasty with Nitroglycerin for Vasospasm after Subarachnoid Hemorrhage: Case Series and Review

Introduction Vasospasm is a common and potentially devastating complication in patients with subarachnoid hemorrhage, causing high morbidity and mortality. There is no effective and consistent way to prevent or treat cerebral vasospasm capable of altering the morbidity and mortality of this complication. Animal and human studies have attempted to show improvement in aneurysmal vasospasm. Some sought their prevention; others, the treatment of already installed vasospasm. Some achieved only angiographic improvement without clinical correlation, others achieved both, but with ephemeral duration or at the expense of very harmful associated effects. Endovascular techniques allow immediate and aggressive treatment of cerebral vasospasm and include methods such as mechanical and chemical angioplasty. These methods have risks and benefits. Objectives To analyze the results of chemical angioplasty using nitroglycerin (GTN). In addition, to perform a comprehensive review and analysis of aneurysmal vasospasm. Methods We describe our series of 77 patients treated for 8 years with angioplasty for vasospasm, either mechanical (with balloon), chemical (with GTN) or both. Results Eleven patients received only balloon; 37 received only GTN; 29 received both. Forty-four patients (70.1%) evolved with delayed cerebral ischemia and 19 died (mortality of 24.7%). Two deaths were causally related to the rupture of the vessel by the balloon. The only predictors of poor outcome were the need for external ventricular drainage in the first hours of admission, and isolated mechanical angioplasty. Conclusions Balloon angioplasty has excellent results, but it is restricted to proximal vessels and is not without complications. Chemical angioplasty using nitroglycerin has reasonable but short-lived results and further research is needed about it. It is restricted to vasospasm angioplasties only in hospitals, like ours, where better and more potent vasodilator agents are not available.

Comparison between laser sheaths, femoral approach and rotating mechanical sheaths for lead extraction

Introduction Efficiency and safety are important features in the selection of lead extraction tools. We report our experience with different endovascular techniques to extract individual pacing and defibrillator leads. Methods This is a single-centre study of consecutive lead extraction procedures from 1997 until 2019. A total of 1725 leads were extracted in 775 patients. Direct traction sufficed for 588 leads, and 22 leads were primarily removed by surgery. The endovascular techniques used in the remainder were a laser sheath (190 leads), the femoral approach (717 leads) and rotating mechanical sheaths (208 leads). Results The three approaches were comparably effective in completely removing the leads (p = 0.088). However, there were more major complications with the laser sheath than with the femoral approach or rotating mechanical sheaths (8.4%, 0.5% and 1.2%, respectively). Therefore, the procedural result—extraction without major complications—was significantly better with both the femoral approach and rotating mechanical sheaths than with the laser sheath (p < 0.001). This result was confirmed after propensity score matching to compensate for differences between lead cohorts (p = 0.007). Cross-over to another endovascular tool was necessary in 7.9%, 7.1% and 8.2% of laser, femoral and rotating mechanical attempts, respectively. Conclusion All three endovascular lead extraction techniques showed comparable efficacy. However, there were significantly more major complications using the laser sheath compared to the femoral approach or rotating mechanical sheaths, leading us to abandon the laser technique. Importantly, no single endovascular technique sufficed to successfully extract all leads.

Complete functional recovery in a child after endovascular treatment of basilar artery occlusion caused by spontaneous dissection: a case report

Stroke caused by dissection of arteries of the vertebrobasilar system in children is still poorly investigated in terms of etiology, means of treatment, course of disease, and prognosis. The aim of this report was to describe the unusual course of a spontaneous dissection of the basilar artery (BA) in a child treated with endovascular techniques and to point out that the plasticity of the brain stem can fully compensate for structural damage caused by stroke. We report the case of a 15-year-old boy who suffered a wake-up stroke with BA occlusion caused by spontaneous dissection. A blood clot was aspirated from the false lumen and the true lumen re-opened, but the patient deteriorated a few hours later, and repeated angiography revealed that the intimal flap was detached, occluding the BA again. The lumen of BA was then reconstructed by a stent. Despite a large pons infarction, the patient was completely recovered 11 months after the onset. The case was analyzed with angiograms and magnetic resonance imaging, macroscopic and microscopic pathological analysis, computed tomographic angiography, magnetic resonance-based angiography, and diffusion tensor imaging. This case illustrates that applied endovascular techniques and intensive care measures can alter the course of potentially fatal brain stem infarction. Our multimodal analysis gives new insight into the anatomical basis for the plasticity mechanism of the brain stem.

Management of Ascending Aorta and Aortic Arch: Similarities and Differences Among Cardiovascular Guidelines

Background: Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular surgery and evolution of open surgery have extended the indications for treatment in patients previously considered unfit for surgery. The aim of this systematic review of the literature was to present and analyze current cardiovascular guidelines for overlap and differences in their recommendations regarding ascending aorta and aortic arch diseases and the assessment of evidence. Methods: The English medical literature was searched using the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 2009 to December 2020. Recommendations on selected topics were analyzed, including issues from definitions and diagnosis (imaging and biomarkers) and indications for treatment to management, including surgical techniques, of the most important ascending aorta and aortic arch diseases. Results: The initial search identified 2414 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from multidisciplinary, cardiovascular societies published between 2010 and 2019. The definition of non-A-non-B aortic dissection is lacking from most of the guidelines. There is a disagreement regarding the class of recommendation and level of evidence for the diameter of ascending aorta as an indication. The indication for treatment of aortic disease may be individualized in specific cases while the growth rate may also affect the decision making. The role of endovascular techniques has not been established in current guidelines except by 1 society. Supportive evidence level in the management of aortic arch diseases remains limited. Conclusion: In current recommendations of cardiovascular societies, the ascending aorta and aortic arch remain a domain of open surgery despite the introduction of endovascular techniques. Recommendations of the included societies are mostly based on expert opinion, and the role of endovascular techniques has been highlighted only from 1 society. The chronological heterogeneity apparent among guidelines and the inconsistency in evidence level should be also acknowledged. More data are needed to develop more solid recommendations for the ascending aorta and aortic arch diseases.

Abstract 1122‐000212: INARI FlowTriever system: First Endovascular Clinical Experience to Treat Diffuse Cerebral Venous Sinus Thrombosis

Introduction : Cerebral Venous Sinus Thrombosis (CVST) is a rare stroke with a wide range of symptomatology at presentation ranging from headache, focal weakness, and coma. Anticoagulation remains the mainstay of treatment. However, in a subset of patients endovascular treatment can be potentially beneficial. Here we describe the first clinical experience using the INARI FlowTriever system to treat a patient presented with focal weakness and found to have diffuse cerebral venous sinus thrombosis. Methods : Case report of CSVT treated with INARI FlowTriever system. Results : A 78‐year‐old female with past medical history of Autoimmune hepatitis and hypothyroidism, was brought to the hospital with left arm weakness. CT head revealed left temporoparietal intraparenchymal hemorrhage and right frontal subarachnoid hemorrhage. CTA of the head and neck revealed extensive CVST involving superior sagittal sinus, bilateral transverse and sigmoid sinuses. She was started on heparin drip. Patient was taken for venous thrombectomy due to persistent left‐sided weakness and multicompartment bleeding while being on anticoagulation for 48 hours. She underwent successful endovascular venous thrombectomy using the INARI FlowTriever system with large clot burden extracted. She was switched to novel oral anticoagulation prior to discharge. During the 3 months follow‐up–MRI brain with and without contrast revealed near complete resolution of the clot burden in the superior sagittal sinus and left transverse/sigmoid complex and her modified Rankin score was at 0. Conclusions : Here we discussed a case of diffuse CVST who was treated initially with heparin drip then underwent endovascular venous thrombectomy using INARI FlowTriever system with large clot burden aspirated with a reasonable safety profile. The INARI medical FlowTriever system is the only mechanical thrombectomy system indicated for the treatment of pulmonary embolism. It is specifically designed for venous clots. It is composed of a trackable large bore aspiration catheter. The INARI FlowTriever Catheter; has 3 expanding nitinol mesh disks; designed to engage and disrupt venous clots and subsequently deliver it to the large bore aspiration catheter. Its larger size makes it an attractive candidate for venous sinus clot retrieval. This study illustrates the first clinical use of INARI thrombectomy device in CVST with a reasonable safety profile. Anticoagulation is the mainstay first line treatment for CVST. However, a small subset of patients would potentially benefit from endovascular treatment but it still uncertain how to select these patients and what is the best timeline to offer early endovascular treatment. Various neuro endovascular techniques has been attempted to treat cerebral venous sinus thrombosis. However; it is unclear which approach and device provides the optimal restoration of venous blood flow. Current neuro endovascular techniques and devices are not particularly designed for CVST pathology treatment and there is need for further innovation and new devices.

Abstract 1122‐000155: Vertebral Artery Origin Treatment by Endovascular Techniques Registry (VOTER): Safety in the First 20 Cases

Introduction : Background: Stenosis of the vertebral artery origin (VAOS), while under‐diagnosed, is common and may cause up to 25% of posterior circulation infarction. Stenting is widely employed as a secondary prevention strategy, but prospective clinical studies of safety and efficacy are limited. Objective: To report periprocedural and 30‐day outcomes after stenting of the vertebral origin in the first 20 patients of the Vertebral Artery Origin Treatment by Endovascular Techniques Registry (VOTER). Methods : VOTER is a prospective, multicenter, cohort study of patients with symptomatic vertebral artery stenosis > = 50%. Demographic, clinical, and procedural data is collected via a RedCap constructed, cloud‐based, data entry portal. In addition, there is clinical follow‐up data collected at 30 days and 1 year. Lesion stenosis[OGS1] percentage along with representative images are collected pre‐stent, post‐stent, and at 1 year for validation by an independent core laboratory. The primary outcome is stroke and death at 30 days. The secondary outcome is restenosis > = 50% at 1 year follow‐up. Results : A total of 10 sites have been activated to enroll in the study. Of these, 3 sites have enrolled a total of 20 subjects. The median age was 64 (range 47–87) years; 14 (70%) were male, and 16 (80%) were white. 19 patients (95%) were hypertensive, with 5 patients (25%) having a history of ischemic heart disease. The median Modified Rankin score (mRS) at admission was 1 (range 0–3). Presenting symptoms included dizziness/vertigo (43%), visual field defects (14.3%), hemiparesis (14.3%), dysarthria (19.0%), diplopia (4.8%), ataxia (4.8%), and dysphasia (4.8%). All patients were treated with dual antiplatelet therapy. All stents utilized were drug eluting. The median pre‐stent stenosis was 80% (range 60–99%) with a median of 15% (range 0–33%) post‐stent residual. There were no periprocedural strokes, death, or technical complications. One month follow up was available in 15 patients (75%), with 2 reporting new neurological symptoms: 1 with blurred vision and 1 with dizziness and facial numbness. No new imaging confirmed infarctions occurred. Symptomatic improvement was noted in 40% of subjects although there was no change in the median 30 day mRS. Conclusions : VOTER is the first large prospective registry of vertebral origin stenting in North America. These early results from the first 20 subjects are consistent with procedural safety and the importance of continued study of stenting as a secondary prevention strategy for posterior circulation infarction in the setting of VAOS.

Use of Distal Intracranial Catheters for Better Working View of Cerebral Aneurysms Hidden by Parent Artery or Its Branches: A Technical Note

A good working view is critical for safe and successful endovascular treatment of cerebral aneurysms. In a few cases, endovascular treatment of cerebral aneurysms may be challenging due to difficulty in obtaining a proper working view. In this report of 6 cases, we described the advantage of using a distal intracranial catheter (DIC) to achieve better visualization of cerebral aneurysms hidden by a parent artery or its branches. Between September 2017 and January 2021, we treated 390 aneurysms with endovascular techniques. In 6 cases in which it was difficult to obtain a proper working view, the DIC was placed distally close to the aneurysm in order to remove the parent artery projection from the working view and obtain better visualization of the aneurysm. Clinical and procedural outcomes and complications were evaluated. The position of the DIC was above the internal carotid artery siphon in the 6 cases. All aneurysms were successfully embolized. Raymond–Roy class 1 occlusion was achieved in all 4 unruptured aneurysms, while the result was class 2 in the 2 ruptured aneurysms. Placement of the DIC was atraumatic without dissections or significant catheter-induced vasospasm in all patients. Transient dysphasia was seen in 2 cases and transient aphasia in 1. Using this technique, we have found it possible to better visualize the aneurysm sac or neck and thereby treat cases we otherwise would have considered untreatable.

Endovascular Management of Unused Fenestrations or Branches in Fenestrated/Branched Aortic Endograft

Fenestrated and branched aortic endograft (F/B EVAR) has become a widely accepted technique in the management of aneurysmal aortic pathology. However, intra-procedurally in some situations, there are F/B that remain unused because of target vessel occlusion or failure to cannulate the target artery. Leaving the F/B open will result in an ongoing endoleak, unless treated at the time. Herein we described the necessary considerations and several endovascular techniques to occlude these fenestrations and branches in this situation.