An interesting case of reruptured endovascularly coiled aneurysm managed with clipping

Endovascular treatment has proven to be effective in the management of intracranial aneurysm, and can achieve permanent occlusion in up to 85% of cases, reducing the bleeding or rebleeding rate. A paradigm shift from microsurgical clipping to endovascular intervention has been observed since the publication of the International Subarachnoid Aneurysm Trial. Aneurysm recurrence after coil embolization remains both a major shortcoming of endovascular treatment and a daunting challenge for neurosurgeons without optimal management strategies.: We present a case report of a patient with history of previously endovascularly coiled and presenting with aneurysmal bleed. Microsurgical clipping is an effective intervention for managing reruptured previously coiled intracranial aneurysm.

Endoscopic Cyanoacrylate Injection Treatment for Refractory High-risk Peptic Ulcer Bleeding by Conventional Endoscopic Therapy

Bleeding is a major and potentially life-threatening complication of peptic ulcer. Despite endoscopic hemostatic therapy advance, conventional endoscopic hemostatic modalities remain refractory for peptic ulcer bleeding with big size, fibrous base or in difficult-to-access anatomical locations. In this study, we attempted to evaluate the efficacy and safety of endoscopic cyanoacrylate injection treatment (ECIT) for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy. The patients with refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy were carried out ECIT. The data were retrospectively collected. A total of 119 patients accepted ECIT. 74 patients (62.18%) obtained successful intravascular injection and perivascular injection was performed in 45 patients (37.82%). Immediate hemostatic rate for active bleeding achieved 90.91%. Rebleeding rate within 30 days was 12.07%. Overall successful hemostasis rate achieved 87.93%. Immediate hemostatic rate and overall successful hemostasis rate in intravascular injection patients were markedly superior over perivascular injection. Rebleeding rate in intravascular injection patients was markedly lower than that in perivascular injection patients. 11 patients complicated abdominal pain and no other complication occurred. In conclusion, ECIT, especial intravascular injection, was effective and safe, with high successful hemostasis rate for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy.

Brainstem Cavernous Malformations Management: Microsurgery vs. Radiosurgery, a Meta-Analysis

Given the rareness of available data, we performed a systematic review and meta-analysis on therapeutic strategy microsurgical resection and stereotactic radiosurgery (SRS) for brainstem cavernous malformations (BSCMs) and assessed mortality, permanent neurological deficits (PNDs), rebleeding rate, and patients who require reintervention to elucidate the benefits of each treatment modality. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used for protocol development and manuscript preparation. After applying all inclusion and exclusion criteria, six remaining articles were included in the final manuscript pool. In total, this meta-analysis included 396 patients, among them 168 patients underwent microsurgical treatment and 228 underwent SRS. Findings of the present meta-analysis suggest that regarding the total group of patients, in terms of mortality, late rebleeding rate, and PNDs, there was no superiority of the one method over the other. Applying the leave-one-out method to our study suggests that with low robust of the results for the bleeding rate and patients who require reintervention outcome factor, there was no statistical difference among the surgical and SRS treatment. Microsurgical treatment of BSCMs immediately eliminates the risk of rehemorrhage; however, it requires complete excision of the lesion and it is associated with a similar rate of PNDs compared with SRS management. Apparently, SRS of BSCMs causes a marked reduction in the risk of rebleeding 2 years after treatment, but when compared with the surgical treatment, there was not any remarkable difference.

Number of Endoscopic Sessions to Eradicate Varices Identifies High Risk of Rebleeding in Cirrhotic Patients

Background and aims: Risk stratification to identify patients with high risk of variceal rebleeding is particularly important in patients with decompensated cirrhosis. In clinical practice, eliminating gastroesphageal varices thoroughly after sequential endoscopic treatment reduces the rebleeding rate, however, no simple method has been build to predict high risk of variceal rebleeding. We conducted this study to explore the value of the number of endoscopic sessions required to eradicate gastroesphageal varices in identifying high risk of rebleeding.Patients and methods: Consecutive cirrhotic patients received sequential endoscopic therapy between January 2015 to March 2020 were enrolled. Endoscopic treatment was performed every 1-4 weeks until the eradication of varices. The primary endpoint was variceal rebleeding.Results: A total of 146 patients were included of which 60 patients received standard therapy and 86 patients underwent sequential endoscopic treatment alone. The cut-off value of the number of sequential endoscopic sessions is 3.5 times. Variceal rebleeding was significant higher in patients with endoscopic sessions > 3 times vs. ≤ 3 times (61.5% vs. 17.5%, p<0.001). Variceal rebleeding of patients with endoscopic sessions ≤3 times was significant lower than patients with > 3 times in group of standard therapy (19.6% vs. 88.9%, p<0.001) and endoscopic therapy (15.9% vs. 47.1%, p=0.028) respectively. Conclusion: The number of sequential endoscopic sessions required to eradicate the varices is related to the risk of variceal rebleeding in patients with cirrhosis. If three times of endoscopic treatment can not eradicate the varices, a more aggressive treatment such as TIPS should be seriously considered.

Outcomes in high and low volume hospitals in patients with acute hematochezia in a cohort study

Outcomes of acute lower gastrointestinal bleeding have not been compared according to hospital capacity. We aimed to perform a propensity score-matched cohort study with path and mediation analyses for acute hematochezia patients. Hospitals were divided into high- versus low-volume hospitals for emergency medical services. Rebleeding and death within 30 days were compared. Computed tomography, early colonoscopy (colonoscopy performed within 24 h), and endoscopic therapies were included as mediators. A total of 2644 matched pairs were yielded. The rebleeding rate within 30 days was not significant between high- and low-volume hospitals (16% vs. 17%, P = 0.44). The mortality rate within 30 days was significantly higher in the high-volume cohort than in the low-volume cohort (1.7% vs. 0.8%, P = 0.003). Treatment at high-volume hospitals was not a significant factor for rebleeding (odds ratio [OR] = 0.91; 95% confidence interval [CI], 0.79–1.06; P = 0.23), but was significant for death within 30 days (OR = 2.03; 95% CI, 1.17–3.52; P = 0.012) on multivariate logistic regression after adjusting for patients’ characteristics. Mediation effects were not observed, except for rebleeding within 30 days in high-volume hospitals through early colonoscopy. However, the direct effect of high-volume hospitals on rebleeding was not significant. High-volume hospitals did not improve the outcomes of acute hematochezia patients.

CLinical Assessment of WEB device in Ruptured aneurYSms (CLARYS): results of 1-month and 1-year assessment of rebleeding protection and clinical safety in a multicenter study

BackgroundThe primary goal of the CLARYS study is to assess the protection against rebleeding when treating ruptured bifurcation aneurysms with the Woven EndoBridge (WEB) device.MethodsThe CLARYS study is a prospective, multicenter study conducted in 13 European centers. Patients with ruptured bifurcation aneurysms were consecutively included between February 2016 and September 2017. The primary endpoint was defined as the rebleeding rate of the target aneurysm treated with the WEB within 30 days postprocedure. Secondary endpoints included periprocedural and postprocedural adverse events, total procedure and fluoroscopy times, and modified Rankin Scale score at 1 month and 1 year.ResultsSixty patients with 60 ruptured bifurcation aneurysms to be treated with the WEB were included. A WEB device was successfully implanted in 93.3%. The rebleeding rate at 1 month and 1 year was 0%. The mean fluoroscopy time was 27.0 min. Twenty-three periprocedural complications were observed in 18 patients and resolved without sequelae in 16 patients. Two of these complications were attributed to the procedure and/or the use of the WEB, leading to a procedure/device-related intraoperative complication rate of 3.3%. Overall mortality at 1 month and 1 year was 1.7% and 3.8%, respectively and overall morbidity at 1 month and 1 year was 15% and 9.6%, respectively. WEB-related 1-month and 1-year morbidity and mortality was 0%.ConclusionsThe interim results of CLARYS show that the endovascular treatment of ruptured bifurcation aneurysms with the WEB is safe and effective and, in particular, provides effective protection against rebleeding. It may induce profound change in the endovascular management of ruptured bifurcation aneurysms.

Increasing the low-risk threshold for patients with upper gastrointestinal bleeding during the COVID-19 pandemic: a prospective, multicentre feasibility study

ObjectiveDuring the COVID-19 pandemic, we extended the low-risk threshold for patients not requiring inpatient endoscopy for upper gastrointestinal bleeding (UGIB) from Glasgow Blatchford Score (GBS) 0–1 to GBS 0–3. We studied the safety and efficacy of this change.MethodsBetween 1 April 2020 and 30 June 2020 we prospectively collected data on consecutive unselected patients with UGIB at five large Scottish hospitals. Primary outcomes were length of stay, 30-day mortality and rebleeding. We compared the results with prospective prepandemic descriptive data.Results397 patients were included, and 284 index endoscopies were performed. 26.4% of patients had endoscopic intervention at index endoscopy. 30-day all-cause mortality was 13.1% (53/397), and 33.3% (23/69) for pre-existing inpatients. Bleeding-related mortality was 5% (20/397). 30-day rebleeding rate was 6.3% (25/397). 84 patients had GBS 0–3, of whom 19 underwent inpatient endoscopy, 0 had rebleeding and 2 died. Compared with prepandemic data in three centres, there was a fall in mean number of UGIB presentations per week (19 vs 27.8; p=0.004), higher mean GBS (8.3 vs 6.5; p<0.001) with fewer GBS 0–3 presentations (21.5% vs 33.3%; p=0.003) and higher all-cause mortality (12.2% vs 6.8%; p=0.02). Predictors of mortality were cirrhosis, pre-existing inpatient status, age >70 and confirmed COVID-19. 14 patients were COVID-19 positive, 5 died but none from UGIB.ConclusionDuring the pandemic when services were under severe pressure, extending the low-risk threshold for UGIB inpatient endoscopy to GBS 0–3 appears safe. The higher mortality of patients with UGIB during the pandemic is likely due to presentation of a fewer low-risk patients.

Observed risk of recurrent bleeding and thromboembolic disease in COVID-19 patients with gastrointestinal bleeding

Background and study aim COVID-19 patients are at increased risk for venous thromboembolism (VTE) requiring the use of anticoagulation. Gastrointestinal bleeding (GIB) is increasingly being reported, complicating the decision to initiate or resume anticoagulation as providers balance the risk of thrombotic disease with the risk of bleeding. Our study aimed to assess rebleeding rates in COVID-19 patients with GIB and determine whether endoscopy reduces these rebleeding events. We also report 30-day VTE and mortality rates. Methods This was a retrospective study evaluating 56 COVID-19 patients with GIB for the following outcomes: 30-day rebleeding rate, 30-day VTE rate, effects of endoscopic intervention on the rate of rebleeding, and 30-day mortality. Results The overall rates of VTE and rebleeding events were 27 % and 41 %, respectively. Rebleeding rates in patients managed conservatively was 42 % compared with 40 % in the endoscopy group. Overall, 87 % of those who underwent invasive intervention resumed anticoagulation vs. 55 % of those managed medically (P = 0.02). The all-cause 30-day mortality and GIB-related deaths were 32 % and 9 %, respectively. Mortality rates between the endoscopic and conservative management groups were not statistically different (25 % vs. 39 %; P = 0.30). Conclusions Although rebleeding rates were similar between the endoscopic and conservative management groups, patients who underwent intervention were more likely to restart anticoagulation. While endoscopy appeared to limit the duration that anticoagulation was withheld, larger studies are needed to further characterize its direct effect on mortality outcomes in these complex patients.

Effectiveness of hemostatic powders in lower gastrointestinal bleeding: a systematic review and meta-analysis

Background and study aims There is limited evidence on the effectiveness of hemostatic powders in the management of lower gastrointestinal bleeding (LGIB). We aimed to provide a pooled estimate of their effectiveness and safety based on the current literature. Patients and methods Literature review was based on computerized bibliographic search of the main databases through to December 2020. Immediate hemostasis, rebleeding rate, adverse events, and mortality were the outcomes of the analysis. Pooled effects were calculated using a random-effects model. Results A total of 9 studies with 194 patients were included in the meta-analysis. Immediate hemostasis was achieved in 95 % of patients (95 % confidence interval [CI] 91.6 %–98.5 %), with no difference based on treatment strategy or bleeding etiology. Pooled 7- and 30-day rebleeding rates were 10.9 % (95 %CI 4.2 %–17.6 %) and 14.3 % (95 %CI 7.3 %–21.2 %), respectively. Need for embolization and surgery were 1.7 % (95 %CI 0 %–3.5 %) and 2.4 % (95 %CI 0.3 %–4.6 %), respectively. Overall, two patients (1.9 %, 95 %CI 0 %–3.8 %) experienced mild abdominal pain after powder application, and three bleeding-related deaths (2.3 %, 95 %CI 0.2 %–4.3 %) were registered in the included studies. Conclusion Novel hemostatic powders represent a user-friendly and effective tool in the management of lower gastrointestinal bleeding.

Treatment of ruptured intracranial aneurysms with the Woven EndoBridge device: a systematic review

The Woven EndoBridge (WEB) device is a barrel-shaped nitinol mesh deployed within the aneurysmal sac. The absence of metallic mesh in the aneurysm’s parent vessel lumen obviates the need for potent antiplatelet therapy, making this device appealing for acutely ruptured aneurysms not amenable to clipping or coiling. To assess the literature regarding WEB treatment of these aneurysms, we performed a comprehensive systematic search of PubMed, MEDLINE, and EMBASE databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Keywords were combined with Boolean operators to increase search sensitivity and specificity (‘woven endobridge device’ AND ‘ruptured’). Nine studies comprising 377 acutely ruptured aneurysms were included. Overall, 82.7% were wide-necked, 85.9% were located in the anterior circulation, and 26.9% of patients presented with poor subarachnoid hemorrhage grade. Intraprocedure and postprocedure complications occurred in 8.4% (95% CI 3.6% to 13.3%) and 1% (95% CI 0% to 2%), respectively. The post-treatment rebleeding rate was 0%. Rates of adequate occlusion (complete occlusion to neck remnant) and retreatment at last follow-up were 84.8% (95% CI 73% to 96.6%) and 4.5% (95% CI 2.2% to 6.8%), respectively. The favorable outcome rate (modified Rankin Scale score 0–2) was 62.2% (95% CI 53% to 71.4%); mortality was 13.6% (95% CI 9.7% to 17.6%). WEB treatment of acutely ruptured aneurysms results in high adequate occlusion rates, low perioperative complication rates, no rebleeding, and low recurrence requiring retreatment. This device is promising for acutely ruptured aneurysms not amenable to clipping or coiling, considering the lower need for antiplatelet regimens during the procedure or follow-up.