Abdul Tarabishy

A population-based incidence of acute large vessel occlusions and thrombectomy eligible patients indicates significant potential for growth of endovascular stroke therapy in the USA

Background Data on large vessel strokes are important for resource allocation and infrastructure development. Objective To determine an annual incidence of large vessel occlusions (LVOs) and a thrombectomy eligible patient population. Methods All patients with acute ischemic stroke discharged over 3 years from a tertiary-level hospital serving a large geographic area were evaluated for an LVO (M1, internal carotid artery terminus, basilar artery). The incidence of LVO was determined for the hospitals 4-county primary service area (PSA, population 210 000) based on each countys discharges and extrapolated to the US population. ‘Thrombectomy eligibility’ for anterior circulation LVOs was based on time (onset <6 hours) and imaging (Alberta Stroke Program Early CT Score (ASPECTS) ≥6). The number of annual thrombectomy procedures was calculated for Medicare and private payer patients using federally available databases. Results 1157 patients were discharged from the hospitals PSA, of whom 129 (11.1%, 95% CI 9.5% to 13.1%) had an LVO. This translated into an LVO incidence of 24 per 100 000 people per year (95% CI 20 to 28). 20 per 100 000 people per year had anterior circulation LVOs (95% CI 19 to 22), of whom 10/100 000/year (95% CI 8 to 11) were ‘thrombectomy eligible’. An additional 5/100 000/year (95% CI 3 to 6) presented with favorable ASPECTS after 6 hours of symptom onset. Basilar occlusion incidence was estimated at 4/100 000/year (95% CI 2 to 5). These rates yield 77 569 (95% CI 65 835 to 91 091) new LVOs per year in the USA. An estimated 10 284 mechanical thrombectomy procedures were performed in 2015. Conclusions This study estimates an LVO incidence of 24 per 100 000 person-years (95% CI 20 to 28). A current estimated annual thrombectomy rate of three procedures per 100 000 people indicates significant potential increase in the volume of endovascular procedures and the need to develop systems of care.

The ‘pit-crew’ model for improving door-to-needle times in endovascular stroke therapy: a Six-Sigma project

Background Delays in delivering endovascular stroke therapy adversely affect outcomes. Time-sensitive treatments such as stroke interventions benefit from methodically developed protocols. Clearly defined roles in these protocols allow for parallel processing of tasks, resulting in consistent delivery of care. Objective To present the outcomes of a quality-improvement (QI) process directed at reducing stroke treatment times in a tertiary level academic medical center. Methods A Six-Sigma-based QI process was developed over a 3-month period. After an initial analysis, procedures were implemented and fine-tuned to identify and address rate-limiting steps in the endovascular care pathway. Prospectively recorded treatment times were then compared in two groups of patients who were treated ‘before’ (n=64) or ‘after’ (n=30) the QI process. Three time intervals were measured: emergency room (ER) to arrival for CT scan (ER–CT), CT scan to interventional laboratory arrival (CT–Lab), and interventional laboratory arrival to groin puncture (Lab–puncture). Results The ER–CT time was 40 (±29) min in the ‘before’ and 26 (±15) min in the ‘after’ group (p=0.008). The CT–Lab time was 87 (±47) min in the ‘before’ and 51 (±33) min in the ‘after’ group (p=0.0002). The Lab–puncture time was 24 (±11) min in the ‘before’ and 15 (±4) min in the ‘after’ group (p<0.0001). The overall ER–arrival to groin-puncture time was reduced from 2 h, 31 min (±51) min in the ‘before’ to 1 h, 33 min (±37) min in the ‘after’ group, (p<0.0001). The improved times were seen for both working hours and off-hours interventions. Conclusions A protocol-driven process can significantly improve efficiency of care in time-sensitive stroke interventions.

Intravenous thrombolysis before endovascular therapy for large vessel strokes can lead to significantly higher hospital costs without improving outcomes

Background Limited efficacy of IV recombinant tissue plasminogen activator (rt-PA) for large vessel occlusions (LVO) raises doubts about its utility prior to endovascular therapy. Purpose To compare outcomes and hospital costs for anterior circulation LVOs (middle cerebral artery, internal carotid artery terminus (ICA-T)) treated with either primary endovascular therapy alone (EV-Only) or bridging therapy (IV+EV)). Methods A single-center retrospective analysis was performed. Clinical and demographic data were collected prospectively and relevant cost data were obtained for each patient in the study. Results 90 consecutive patients were divided into EV-Only (n=52) and IV+EV (n=38) groups. There was no difference in demographics, stroke severity, or clot distribution. The mean (SD) time to presentation was 5:19 (4:30) hours in the EV-Only group and 1:46 (0:52) hours in the IV+EV group (p<0.0001). Recanalization: EV-Only 35 (67%) versus IV+EV 31 (81.6%) (p=0.12). Favorable outcome: EV-Only 26 (50%) versus IV+EV 22 (58%) (p=0.45). For patients presenting within 4.5 hours (n=64): Recanalization: EV-Only 21/26 (81%) versus IV+EV 31/38 (81.6%) (p=0.93). Favorable outcome: EV-Only 14/26 (54%) versus IV+EV 22/38 (58%) (p=0.75). There was no significant difference in rates of hemorrhage, mortality, home discharge, or length of stay. A stent retriever was used in 67 cases (74.4%), with similar recanalization, outcomes, and number of passes in the EV-Only and IV+EV groups. The mean (SD) total hospital cost was

Transcatheter closure of an aortoatrial fistula following a surgical aortic valve replacement

33 810 (13 505) for the EV-Only group and

Transcatheter closure of a residual aortopulmonary window defect

40 743 (17 177) for the IV+EV group (p=0.02). The direct cost was

Incidence and Outcomes of Myocardial Infarction in Patients Admitted With Acute Ischemic Stroke

23 034 (8786) for the EV-Only group and

Percutaneous closure of left ventricular pseudoaneurysm caused by a central venting cannula

28 711 (11 406) for the IV+EV group (p=0.007). These significantly higher costs persisted for the subgroup presenting in <4.5 hours and the stent retriever subgroup. IV rt-PA administration independently predicted higher hospital costs. Conclusions IV rt-PA did not improve recanalization, thrombectomy efficacy, functional outcomes, or length of stay. Combined therapy was associated with significantly higher total and direct hospital costs than endovascular therapy alone.

A population-based incidence of M2 strokes indicates potential expansion of large vessel occlusions amenable to endovascular therapy

Aorto‐atrial fistulas are rare complications of aortic valve replacement. We report a case of a post‐aortic valve replacement aorto‐atrial fistula that was closed percutaneously with an Amplatz Ductal Occluder‐II device.

Stereotactic radiosurgery planning based on time-resolved CTA for arteriovenous malformation: a case report and review of the literature

A 35-year-old male who underwent surgical closure of an aortopulmonary window (APW) defect at 6 weeks of age, presented with increasing dyspnea on exertion, and recurrent episodes of symptomatic atrial arrhythmias. Echocardiography suggested left to right shunting at the level of the pulmonary artery (PA) (Video S1). Cardiac computed tomography confirmed the presence of an aortopulmonary fistula (Figure 1). A cardiac catheterization revealed a PA pressure of 48mmHg, amean pulmonarywedge pressure of 14mmHg, pulmonary vascular resistance of 2.3 wood units, and a shunt fraction (QP/QS) of 2.3. Intracardiac echocardiography (ICE) confirmed the presence of a

P-002 The Financial Impact of Flow Diverters on The Endovascular Treatment of Cerebral Aneurysms

Background and Purpose— Data on the incidence and outcomes of acute myocardial infarction (AMI) complicating acute ischemic stroke (AIS) are limited. We aim to evaluate the incidence, treatment patterns, and outcomes of AMI in patients with AIS using a nationwide database. Methods— The National Inpatient Sample was used to identify patient with AIS between 2003 and 2014. Trends of incidence of AMI and its associated in-hospital mortality were evaluated. Univariate and multivariate logistic regressions were used to evaluate predictors of AMI. The impact of AMI on in-hospital outcomes was assessed in a comparative analysis of propensity-matched groups of patients with and without AMI. Results— Patients with AIS (n=864 043) were identified in the national inpatient sample, of whom 13 573 patients (1.6%) had an AMI (79.5% non–ST-segment–elevation myocardial infarction and 20.5% ST-segment–elevation myocardial infarction). In-hospital mortality was 21.4% and 7.1% in propensity-matched cohorts of patients with and without AMI, P<0.001. In-hospital length of stay and cost of care were 50% higher in the AMI group. In a multivariate logistical regression analysis, the strongest predictors of having AMI after AIS were older age, history of coronary artery disease, chronic renal insufficiency, undergoing mechanical thrombectomy, and rhythm and conduction abnormalities. In the AMI group, undergoing coronary angiography and undergoing percutaneous coronary intervention both strongly correlated with lower in-hospital mortality (odds ratio, 0.34 [confidence interval, 0.23–0.51] and 0.26 [confidence interval, 0.20–0.34], respectively, P<0.001). However, these were only performed in 7.5% and 2% of patients, respectively. Conclusions— AMI complicating stroke carries a substantial in-hospital mortality and cost of care. Patients who underwent coronary angiography with or without intervention may have improved survival although it was only utilized in a minority of patients. Further studies needed to discern the ideal approach in AMI in patients with AIS.