Gaurav Jindal

Incidence of Contrast Material–induced Nephropathy after Neuroendovascular Procedures

PURPOSE To report the incidence and risk factors for contrast material ( CM contrast material )-induced nephropathy ( CIN CM-induced nephropathy ) in patients with no history of chronic kidney disease and estimated glomerular filtration rate that exceeded 30 mL/min/1.73 m(2) after a relatively high dose of CM contrast material (≥250 mL) during neuroendovascular procedures. MATERIALS AND METHODS An institutional review board-approved retrospective chart review was performed for all patients who received a dose of CM contrast material 250 mL or greater while they underwent a neuroendovascular procedure between January 2011 and February 2013. The control group consisted of comparable patients who received a CM contrast material dose of 75-249 mL during the same period. Patients with pre-existing estimated glomerular filtration rate of 30 mL/min/1.73 m(2) or less or documented history of chronic kidney disease were excluded. CIN CM-induced nephropathy was defined as an increase in serum creatinine 50% above the baseline or an absolute increase of 0.3 mg/dL at either 24 or 48 hours after the procedure. Statistical analysis was performed with the Student t test, χ(2) analysis, and mixed-model analysis of variance. RESULTS Clinical characteristics between the control and high-dose group were similar for age (95% confidence interval [CI]: -3.69, 5.48; P = .70), sex (95% CI: 0.28, 0.43; P = .62), and ethnicity (95% CI: 0.42, 0.58; P = .47). The average volume of CM contrast material administered was 172 mL in the control group and 326 mL in the high-dose cohort (95% CI: 131.78, 175.05; P < .001). Of the 79 cases in the high-dose cohort, 36 (46%) received a CM contrast material dose between 250 and 299 mL, 29 (37%) received 300-399 mL, nine (11%) received 400-499 mL, and five (6%) received greater than 500 mL. By 48 hours, a statistically significant decrease in serum creatinine was seen in two of the four high-dose CM contrast material dose categories: 250-299 mL (decrease of 24%; [95% CI: 0.04, 0.36]; P = .003) and greater than 500 mL (decrease of 14% [95% CI: -0.33, 0.57]; P = .007). There were four cases (5%) of CIN CM-induced nephropathy : three (4%) at 24 hours and one (1%) at 48 hours. The comorbid rate of diabetes (25% vs 15% [95% CI: -0.01, 0.04]; P < .001) was found to be higher among those who developed CIN CM-induced nephropathy compared with those who did not within the high-dose cohort. No cases of CIN CM-induced nephropathy occurred in the control group. CONCLUSION Risk of developing CIN CM-induced nephropathy is relatively low in patients who undergo neuroendovascular procedures with CM contrast material doses of 250 mL or greater.

Advances in Multiple Sclerosis and its Variants: Conventional and Newer Imaging Techniques

Multiple sclerosis (MS) and its variants are inflammatory as well as neurodegenerative diseases that diffusely affect the central nervous system (CNS). There is a poor correlation between traditional imaging findings and symptoms in patients with MS. Current research in conventional magnetic resonance (MR) imaging of MS and related diseases includes optimization of hardware and pulse sequences and the development of automated and semiautomated techniques to measure and quantify disease burden. Advanced nonconventional MR techniques such as diffusion tensor and functional MR imaging probe the changes found in the CNS, and correlate these findings with clinical measures of disease.

Micro Vascular Plug (MVP)-assisted vessel occlusion in neurovascular pathologies: technical results and initial clinical experience

Background Deconstructive approaches may be necessary to treat a variety of neurovascular pathologies. Recently, a new device has become available for endovascular arterial occlusion that may have unique applications in neurovascular disease. The Micro Vascular Plug (MVP, Reverse Medical, Irvine, California, USA) has been designed for vessel occlusion through targeted embolization. Purpose To report the results from our initial experience with eight consecutive patients in whom the MVP was used to achieve endovascular occlusion of an artery in the head and neck. Methods Eight consecutive patients treated over a nine-month period were included. The patients’ radiographic and electronic medical records were retrospectively reviewed. Specifically demographic information, clinical indication, site of arterial occlusion, size of MVP, time to vessel occlusion, clinical complications, use of other secondary embolic agents, and clinical outcome were recorded. Follow-up information when available is presented. Results The MVP was used in eight patients for the treatment of neurovascular disease. Indications for treatment included post-traumatic head/neck bleeding (n=3), carotid–cavernous fistula (1), vertebral–vertebral fistula (1), giant fusiform vertebral aneurysm (1), stump-emboli after carotid dissection (1), and iatrogenic vertebral artery penetrating injury (1). One device was used in five patients, two in two patients, and one patient with extensive vertebral–vertebral venous fistula required three plugs to effectively trap the fistula from proximal and distal aspects. Vessel occlusion was obtained in <2 min in each case and there were no procedural complications. Four patients were followed up and no incidence of plug migration or vessel recanalization was seen. Conclusions To the best of our knowledge, this is the first series reporting the use of MVP in neurovascular disease. Use of this device may be associated with shorter procedural times and cost savings in comparison with the use of microcoils for vessel occlusion. Our experience shows that MVP can have unique applications in neurovascular pathologies and it complements other occlusive devices.

Interventional neuroradiology applications in otolaryngology, head and neck surgery.

A review of the current clinical applications of a variety of percutaneous and endovascular interventional procedures of the extracranial head and neck is presented. After a description of general principles and embolic agents for interventional procedures, management of specific disorders is presented and procedural steps are described for epistaxis, embolization of vascular head and neck tumors, high-flow and low-flow cervical vascular malformations, head and neck trauma and bleeding, radiofrequency ablation and cryoablation of tumors, along with percutaneous biopsy within the head and neck.

Use of Pipeline Flex is associated with reduced fluoroscopy time, procedure time, and technical failure compared with the first-generation Pipeline embolization device

Background Flow diversion with the Pipeline embolization device is a well-established method of intracranial aneurysm treatment. However, deployment of the first-generation device (Pipeline Classic) can be technically challenging. The Pipeline Flex contains the same flow-diverting stent with a modified delivery system. Objective To compare procedural outcomes between the first-generation device (Pipeline Classic) and the Pipeline Flex. Methods Thirty-eight of the first 40 consecutive patients who underwent intracranial aneurysm treatment with the Pipeline Flex and 58 of the most recent 60 consecutive patients who underwent treatment with the Pipeline Classic at our institution were evaluated. Patient demographics, aneurysm characteristics, technical procedural details, and early outcomes were analyzed. Results The two groups were comparable for age, gender, and location of target aneurysms. Use of Pipeline Flex decreased procedure time by 44.2 min (p≤0.001) and fluoroscopy time by 22.0 min (p=0.001) compared with the Pipeline Classic. Similarly, radiation exposure was less in the Flex group with a mean difference of 3473.5 Gy cm2 (p=0.002), while contrast usage was decreased with a mean difference of 22.3 mL (p=0.007). These differences remained significant in multivariate regression analysis. Finally, the rate of device deployment failure was lower in the Flex group (7.1%) than in the Classic group (23.9%) (p=0.034). Conclusions Use of Pipeline Flex significantly reduces the total procedure and fluoroscopy time, contrast usage, patient radiation exposure, and proportion of recaptured devices in comparison with the Pipeline Classic, probably owing to an enhanced delivery system that allows for more reliable and controlled deployment.

Pipeline endovascular reconstruction of traumatic dissecting aneurysms of the intracranial internal carotid artery

A 22-year-old woman was involved in a motor vehicle collision resulting in multiple facial fractures and extensive internal carotid artery (ICA) injury including a right carotid-cavernous fistula, complex dissection flap and dissecting aneurysms. Endovascular coil embolization was initially performed to treat the cavernous carotid fistula and then again on two separate occasions to treat expanding dissecting aneurysms. Parent vessel reconstruction of the right ICA was subsequently performed with the Pipeline embolization device, resulting in complete anatomical restoration of this vessel.

Low-angle Vascular Access for Neurovascular Procedures Using the Arstasis AXERA Access Device

PURPOSE To evaluate the safety and efficacy of the Arstasis AXERA access device in patients undergoing neuroendovascular procedures. MATERIALS AND METHODS A single-center retrospective study of 94 patients undergoing neurovascular procedures with the use of an AXERA arterial access device was performed. The procedures were performed with 5-6-F vascular sheaths, and hemostasis was obtained with manual compression. RESULTS A total of 104 neurovascular procedures (81 diagnostic, 23 interventional) were performed in 94 subjects. Eighty-seven procedures (83%) were performed with a 5-F sheath, and 17 procedures (16%) used a 6-F sheath. Intravenous heparin was administered in 64 procedures (61%), and 32 patients (30%) were taking antiplatelet medications at the time of the procedure. Median time to hemostasis was 4 minutes with manual compression, and outpatients undergoing diagnostic angiography were permitted to ambulate at 1 hour. Complications occurred in a total of 3% of cases; these included one local hematoma (1%) and two failed procedures (2%). CONCLUSIONS The new AXERA arterial access device modifies the arterial puncture angle in an attempt to reduce manual compression and ambulation times.

Cerebral Infarction due to Central Vein Occlusion in a Hemodialysis Patient

Venous congestive encephalopathy is a rare complication of central venous occlusion in hemodialysis patients with upper extremity dialysis created shunts. We describe the clinical presentation and endovascular management of an end‐stage renal disease patient with a left upper extremity arteriovenous graft who developed intracranial venous hypertension, left‐sided subdural and subarachnoid intracranial hemorrhage, and left‐sided cerebral infarcts related to a left brachiocephalic vein occlusion.

Endovascular stent repair of traumatic cervical internal carotid artery injuries.

Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American College of Surgeons and the American Association for the Surgery of Trauma. The American College Surgeons is accredited by the ACCME to provide continuing medical education for physicians. AMA PRA Category 1 Creditsi The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Crediti. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Of the AMA PRA Category 1 Crediti listed above, a maximum of 1 credit meets the requirements for self-assessment.

Impact of Endovascular Technique on Fluoroscopy Usage: Stent-Assisted Coiling versus Flow Diversion for Paraclinoid Internal Carotid Artery Aneurysms.

Flow diversion is increasingly being utilized for the treatment of internal carotid artery (ICA) aneurysms. The purpose of this study was to evaluate the impact of endovascular technique-flow diversion versus stent-assisted coiling (SAC) on fluoroscopy time in patients treated for wide-neck paraclinoid ICA aneurysms. A retrospective review identified the 20 most recent consecutive patients treated for wide-neck paraclinoid ICA aneurysms by flow diversion and SAC respectively. Fluoroscopy time, cumulative dose area-product (DAP), contrast usage, intra-procedural complications, and total procedure time were collected and compared between the two treatment techniques. Treatment groups were comparable in terms of demographics, contrast usage, and clinical and angiographic outcomes. Flow diversion was associated with a significant reduction in fluoroscopy time (52.0 minutes versus 77.4 minutes), and demonstrated a strong trend towards shorter total procedure time (172 minutes versus 202 minutes). Average patient radiation exposure as measured by DAP was lower in the flow diversion group, 13225 mGy x cm 2 versus 15124 mGy x cm 2, although this finding was not statistically significant. There was no significant difference in contrast usage between the two groups, 152 ml and 159 (flow diversion and SAC respectively). The rate of complete aneurysm occlusion was higher in the flow diversion group (80% versus 60%). Endovascular treatment of paraclinoid ICA aneurysms with flow diversion is associated with shorter fluoroscopy times compared to stent-assisted coiling. There is also a likely reduction in overall procedure time. These results should be considered when recommending a treatment course for patients with such lesions.