The Role of RIPC in Preventing Organ Damage, Inflammation, and Oxidative Stress during Lower Limb DSA: A Randomised Controlled Trial

Objective. Diagnostic digital subtraction angiography (DSA) and DSA with percutaneous transluminal angioplasty (DSA-PTA) are common procedures for diagnosing and treating symptomatic lower extremity arterial disease (LEAD). However, organ damage following DSA and DSA-PTA is often underrecognised and hence undiagnosed. To reduce the risk induced by invasive procedures in symptomatic LEAD patients, the method of remote ischemic preconditioning (RIPC) has been suggested. The aim of the current study was to assess the effect of RIPC intervention on the organ damage markers profile, oxidative stress, and inflammation biomarkers in LEAD patients undergoing DSA and DSA-PTA procedure. Methods. The RIPC intervention was performed by inflating a standard blood pressure cuff on the patient’s upper arm to 200 mmHg for 5 minutes four times with 5-minute perfusion between each cycle. The sham intervention was performed similarly, but the cuff was inflated to 20 mmHg. Changes in the cardiac and renal damage biomarkers’ profile, oxidative stress, and inflammation biomarkers were recorded before and 24 hours after DSA or DSA-PTA. Results. A total of 111 (RIPC 54, sham 57) patients with symptomatic LEAD scheduled for endovascular procedure were randomised, and 102 patients (RIPC 47, sham 55) completed the study protocol. RIPC significantly limited the increase of adiponectine levels after DSA and DSA-PTA, compared to sham intervention ( p = 0.020 ), but CK-MB levels were markedly lower in the sham group ( p = 0.047 ) after procedure. There was no significant difference between the RIPC and the sham group in mean changes in hs-troponin-T ( p = 0.25 ), NT-proBNP ( p = 0.24 ), creatinine ( p = 0.76 ), eGFR ( p = 0.61 ), urea ( p = 0.95 ), beta-2-microglobuline ( p = 0.34 ), or cystatine C ( p = 0.24 ) levels. Conclusion. In this controlled clinical study, RIPC failed to improve the profile of renal and cardiac biomarkers in patients with LEAD periprocedurally. RIPC significantly limits the rise in adiponectin levels and may influence the decrease of CK-MB levels 24 hours after endovascular procedure.

Seizures 3 Months After Endarterectomy

A 57-year-old woman had development of acute-onset, right-sided weakness and sensory change (face, arm, and leg) when at a casino. She was brought to the emergency department, and her symptoms had essentially resolved upon her arrival. Brain magnetic resonance imaging showed no acute stroke, and a transient ischemic attack was diagnosed. She was transferred to an academic medical center. Investigations showed high-grade left internal carotid artery stenosis; the same day, a stent was placed via endovascular procedure by an interventional neuroradiologist. Magnetic resonance imaging of the head showed an enhancing lesion with surrounding edema in the left frontal and parietal lobes at the cortex, also involving the nearby leptomeninges. Electroencephalography showed potentially epileptogenic discharges over the left central head region. Brain biopsy was performed, which showed abundant CD68+ macrophages, granulomatous inflammation, and necrosis associated with foreign material. The associated lymphocytic infiltrates were predominantly composed of CD3+ T cells and only sparse CD20+ B cells. The foreign material seen was lamellated, amorphous, nonpolarizable, and nonrefractile, typical of hydrophilic polymers commonly used in intravascular medical devices. The patient was diagnosed with seizures caused by multifocal, intracranial, foreign-body, granulomatous reaction to polymers that had embolized to brain parenchyma during the prior endovascular procedure. To suppress this inflammatory reaction, corticosteroids were initiated—intravenous methylprednisolone, followed by an oral prednisone course, with a plan to gradually taper. Antiseizure medication was continued at the same doses. The patient’s seizures remitted initially but relapsed upon corticosteroid dose reduction despite a very slow prednisone taper. At that point, 18 months after the initial onset of seizures, the patient had cushingoid features, depression, and chronic insomnia. During the next year, 2 steroid-sparing strategies were employed sequentially. In patients who have received neurovascular medical device therapy and have subsequent development of seizures, focal neurologic deficit, headache, or encephalopathy, central nervous system inflammation triggered by retained foreign-body material should be considered as a potential cause.

Experience of Managing Suspected Placenta Accreta Spectrum with or without Internal Iliac Artery Balloon Occlusion in Two Lithuanian University Hospitals

Background and objectives: Placenta previa and placenta accreta spectrum are considered major causes of massive postpartum hemorrhage. Objective: To determine whether the placement of an occlusion balloon catheter in the internal iliac artery could reduce bleeding and other related complications during cesarean delivery in patients with placenta previa and placenta accreta spectrum. Materials and Methods: A retrospective analysis was conducted at two tertiary obstetric units of Lithuania. From January 2016 to November 2019 patients with placenta previa and antenatally suspected invasive placenta were included in the intervention group and underwent cesarean delivery with endovascular procedure. From January 2014 to December 2015 patients with placenta previa and suspected placenta accreta spectrum were included in the non-intervention group. The primary outcomes were reduction in intraoperative blood loss and transfusion volumes in the intervention group. Secondary outcomes were the incidence of hysterectomy and maternal complications. Results: Nineteen patients underwent cesarean delivery with preoperative endovascular procedure, and 47 women underwent elective cesarean delivery. The median intraoperative blood loss (1000 (400–4500) mL vs. 1000 (400–5000) mL; p = 0.616) and the need for red blood cell transfusion during operation (26% vs. 23%; p = 0.517) did not differ significantly between the patients groups. Seven patients in the intervention group and two patients in the non-intervention group underwent perioperative hysterectomy (p = 0.002). None of the patients had complications related to the endovascular procedure. Conclusion: The use of intermittent balloon occlusion catheter in patients with placenta pathology is a safe method but does not significantly reduce intraoperative blood loss during cesarean delivery.

Contrast-enhanced encephalopathy and massive cerebral edema after endovascular coiling of cerebral aneurysm. A case report

Contrast-induced encephalopathy (CIEP) is a rare complication after endovascular therapy. The etiology of CIEP is still a matter of debate. We present a rare occurrence of CIEP in a known hypertensive and type 2 diabetic patient after endovascular coiling of cerebral aneurysm with oculomotor nerve palsy. A 68-year old female presented with seven days history of headache and left ptosis or blepharoptosis with mild mydriasis. The headaches were localized mainly at the left side of the nose, orbit, and upper forehead while the left ptosis was associated with blurred vision. Computed tomography angiography revealed an aneurysm in between the C4 segment of the left internal carotid artery (ICA) and the bifurcation of the left posterior communicating artery. Digital subtraction angiography further confirmed the aneurysm. We used the transarterial approach to assess the aneurysm and subsequent coiling. Iohexol (Omnipaque) contrast agent was used during the endovascular procedure. The patient’s condition deteriorated into acute confusion state with cardinal symptomology of CIEP immediately after the operation. Computed tomography scan revealed cortical contrast enhancement in the vascular territory of the ICA as well as edema. Her symptomatology resolved 48 hours after treated with anticonvulsants, intracranial pressure reduction and hydration. Chronic hypertension as well as type 2 diabetics may be critical predisposing factors to CIEP. CIEP should be suspected in patients presenting with acute confusion state after endovascular therapy. Massive edema with ischemic brain changes in white matter of the brain before endovascular procedure should rise suspicion of CIEP.

Stenting for Symptomatic Intracranial Vertebrobasilar Artery Stenosis in Northeast of China: A Single-Center Study

Objective: We described the incidence of surgery-related complications to evaluate the safety of endovascular therapy for severe symptomatic intracranial vertebral basilar artery stenosis (IVBS) in our stroke center in Northeast of China.Methods: Consecutive patients with symptomatic IVBS caused by 70–99% stenosis despite standard medical treatment of antiplatelet agents plus statin were enrolled. Either balloon-mounted stent or balloon predilation plus self-expanding stent was performed. Clinical adverse events such as stroke, transient ischemic attack (TIA), and death after the surgery were documented. Radiological events such as in-stent thrombosis, dissection, and guide-wire perforation during the process were recorded as complications as well. The baseline characteristics and outcomes of patients among different Mori types were compared.Results: From January 2017 to December 2018, 97 patients with stroke or TIA due to intracranial IVBS were treated by stenting, including 30 patients with basilar artery (BA) stenosis, 55 patients with intracranial vertebral artery (V4) stenosis, and 12 patients with V4-BA stenosis. The primary events include two intracranial hemorrhage (2.1%, 2/97), seven ischemic events (7.2%, 7/97), and two death (2.1%, 2/97). The successful stent deployment rate was 98.9% (96/97). The Apollo stents were used more for Mori A lesions. Self-expanding stents were more used in Mori C lesions. Mori C lesions were more vulnerable to endovascular procedure and showed higher rate of complications than A (p = 0.008) and B type (p = 0.047).Conclusion: A high technical success rate of IVBS stenting could be achieved, and the safety was acceptable, whereas Mori C lesions were more vulnerable to endovascular procedure and showed a higher rate of complications than A and B types.