John Perl

Angioplasty and primary stenting of the subclavian, innominate, and common carotid arteries in 83 patients

PURPOSE The initial and long-term results of angioplasty and primary stenting for the treatment of occlusive lesions involving the supra-aortic trunks were studied. METHODS All patients in whom angioplasty and stenting of the supra-aortic trunks was attempted were included in a prospective registry. Results are, therefore, reported on an intent-to-treat basis. The preprocedural and postprocedural clinical records, arteriograms, and noninvasive vascular laboratory examinations of 83 patients (41 men [49.4%] and 42 women [50.6%]; mean age at intervention, 63 years) in whom endovascular repair of the subclavian (66, 75.9%), left common carotid (14, 16.1%), and innominate (7, 8.0%) arteries was attempted were retrospectively reviewed. RESULTS Initial technical success was achieved in 82 of 87 procedures (94.3%). The inability to cross 4 complete subclavian occlusions and the iatrogenic dissection of 1 common carotid artery lesion accounted for the 5 initial failures. Complications occurred in 17.8% of 73 subclavian and innominate procedures, including access-site bleeding in 6 and distal embolization in 2. Ischemic strokes occurred in 2 of 14 common carotid interventions (14.3%), both of which were performed in conjunction with ipsilateral carotid bifurcation endarterectomy. The 30-day mortality rate was 4.8% for the entire group. By means of life-table analysis, 84% of the subclavian and innominate interventions, including initial failures, remain patent by objective means at 35 months. No patients have required reintervention or surgical conversion for recurrence of symptoms. Of the 11 patients available for follow-up study who underwent common carotid interventions, 10 remain stroke-free at a mean of 14.3 months. CONCLUSION Angioplasty and primary stenting of the subclavian and innominate arteries can be performed with relative safety and expectations of satisfactory midterm success. Endovascular repair of common carotid artery lesions can be performed with a high degree of technical success, but should be approached with caution when performed in conjunction with ipsilateral bifurcation endarterectomy.

Early treatment of ruptured aneurysms with Guglielmi detachable coils: effect on subsequent bleeding.

The major causes of mortality and morbidity in patients surviving the rupture of a saccular aneurysm are subsequent bleeding and vasospasm. The purpose of this study was to evaluate the influence of early treatment of ruptured aneurysms with Guglielmi detachable coils on the incidence of subsequent bleeding. Thirteen patients were treated within 72 hours of initial aneurysm rupture with Guglielmi detachable coils. Excluding three patients who died 2, 4, and 12 weeks after initial hemorrhage, all others have been followed up for intervals between 6 and 36 months (mean, 16 mo). None of these have had either clinical or radiographic evidence of subsequent bleeding. Assuming that there is a 30% incidence of subsequent bleeding in conservatively (nonsurgically) treated patients, the 0% subsequent bleed rate observed in this subgroup was significant at a P value of 0.01. Only one procedure-related complication occurred in this series, and 9 of 13 (69%) aneurysms were 100% occluded at the time of initial treatment. All aneurysms were at least 90% occluded at the end of initial treatment. In addition to reducing the risk of subsequent bleeding, early treatment facilitated the institution of an aggressive approach for management of both vasospasm and increased intracranial pressure. Patient outcome, as measured by the Glasgow Outcome Scale, was good in 9 of 13 (69%), poor in 1 of 13 (8%), and death in 3 of 13 (23%) patients. The results of this study suggest that early Guglielmi detachable coil treatment of ruptured aneurysms may be effective in reducing the incidence of subsequent bleeding and can be performed with a low incidence of complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Early Treatment of Ruptured Aneurysms with Guglielmi Detachable Coils

ABSTRACTTHE MAJOR CAUSES of mortality and morbidity in patients surviving the rupture of a saccular aneurysm are subsequent bleeding and vasospasm. The purpose of this study was to evaluate the influence of early treatment of ruptured aneurysms with Guglielmi detachable coils on the incidence of sub

Intra-arterial thrombolysis for perioperative stroke after open heart surgery

Article abstract Recent major surgery is an exclusion criterion for thrombolysis. Six patients with acute ischemic stroke underwent intra-arterial thrombolysis after recent open heart surgery without clinically significant bleeding complications, although one patient developed a small, asymptomatic cerebellar hemorrhage. Intra-arterial thrombolysis may be an option for patients with cerebral embolism in the perioperative period.

Safety and performance of a novel intravascular catheter for induction and reversal of hypothermia in a porcine model.

OBJECTIVE: This study was undertaken to assess the acute safety and feasibility of rapidly inducing, maintaining, then reversing hypothermia using a novel heat transfer catheter and a closed-loop automatic feedback temperature control system to overcome limitations imposed by current clinical practices used for perioperative cooling and warming. METHODS Six swine (mean mass, 53.8 ± 3.6 kg) were studied. The heat transfer catheter was placed in the inferior vena cava via the femoral vein. Hypothermia to 32°C was induced, maintained for 6 hours, then reversed to 36°C. The time needed to induce and reverse hypothermia was recorded via continuous temperature monitoring of the lower esophagus, cerebrum, and rectum. Electrocardiography provided continuous monitoring, and blood draws were made at baseline and at 2-hour intervals. Examination of the catheter in situ was performed after the animals were killed. RESULTS Cooling from 36.2 to 32.0°C was rapid and uniform (mean, 7.3 ± 0.7°C/h), with animals reaching the target temperature within 60 minutes. Rewarming was also easily controlled, with animals’ temperatures reaching 36°C within 130 minutes. No arrhythmia was observed, and all hematological variables were within the normal range for swine. There was no evidence of hemolysis or platelet changes. Little to no thrombosis was observed. CONCLUSION The data presented here suggest that rapid induction and reversal of hypothermia are technically possible using a core intravenous cooling catheter; this method would provide a safe, rapid, and exquisitely reproducible way to induce hypothermia with subsequent restoration of normothermia.

Endovascular Management of Unusual Aneurysms of the Axillary and Subclavian Arteries

Purpose: Aneurysms of the upper extremity arteries are uncommon and may be difficult to manage with standard surgical techniques. We report the exclusion of three axillary-subclavian aneurysms with covered stents. Methods and Results: Palmaz stents were covered with either polytetrafluoroethylene (2 cases) or brachial vein and deployed to exclude pseudoaneurysms in 1 axillary (ruptured) and 2 left subclavian arteries. Two of the patients had advanced cancer and died within 52 days and 3 months of treatment, but their aneurysms were occluded at the time of their death. The repair in the third patient is patent at 9 months. Conclusions: Endovascular exclusion of axillary and subclavian aneurysms with covered stents may offer a useful alternative to operative repair, particularly in patients with significant comorbidities.

Cerebral embolism associated with left ventricular assist device support and successful therapy with intraarterial urokinase

A patient with a bioprosthetic aortic valve sustained a cerebral embolism during support with an implantable left ventricular assist device. This was lysed with intraarterial urokinase with complete resolution of the neurological deficit. Subsequently the patient underwent heart transplantation and remains neurologically intact. This case report is the first successful use of thrombolysis for cerebral embolism associated with a mechanical assist device.

Imaging of Tumors in Epilepsy

Publisher Summary This chapter discusses imaging of tumors in epilepsy. Magnetic resonance imaging (MRI) is the imaging modality of choice in the evaluation of seizures and is clearly superior to computerized tomography (CT) in its ability to demonstrate structural abnormalities. Up to 70% of patients being evaluated for epilepsy surgery and with a normal CT will demonstrate a structural abnormality on MRI. MRI is particularly more sensitive than CT in detecting temporal lobe lesions. Pilocytic astrocytomas (PAs) or juvenile pilocytic astrocytomas represent a distinct, biologically indolent, low-grade variant of astrocytomas. On MRI, PAs are well defined lesions that are intense or slightly hypointense relative to brain on Tl-weighted and hyperintense on T2-weighted images. Pleomorphic xanthoastrocytomas are rare, cortical, supratentorial lesions that usually occur in the temporal lobe, are frequently associated with a long-standing history of seizures. Gangliogliomas are slow-growing, low-grade central nervous system tumors, characterized by a mixture of glial cells and neuronal cells. Gangliogliomas can be indistinguishable from pilocytic astrocytomas on imaging, but should be considered in any young patient with seizures and a temporal lobe lesion. It is found that differentiating Meningioangiomatosis from low-grade astrocytoma, oligodendroglioma, ganglioglioma, and meningioma may be difficult based on imaging.

Thrombolytic Therapy for Acute Non-Hemorrhagic Cerebral Infarction

of initial NlHSSS >10 in the NINDS study (42%). PROACf II ended patient accrual August 24, 1998, and results may be available by this meeting. In the future, LIF reports must include documentation of the initial neurologic deficit, as measured by the NIHSSS, and outcomes as measured by the Barthel Index and Rankin Score, so relative comparison to NlNDS and ECASS data can be derived. Stratification for treatment based on initial NIHSSS or early imaging to document the area of infarction and potential major vessel occlu. sion is a concept that is being pursued. Documentation that LIF is superior to IV therapy in clinical benefit, with acceptable safety, awaits a comparison study of IV-tPA versus IA LIF or some other therapy that allows direct clot removal, with or without additional combination therapy.

The management of arteriovenous malformations of the head and neck

Arteriovenous malformations are uncommon vascular lesions of developmental origin characterized by abnormal communications between arteries and veins. Although present at birth, they usually become apparent during late infancy or childhood, grow proportionately with the child, and fail to regress. Imaging studies accurately define the location and extent and show the serpentine signal voids characteristic of these high-flow lesions. Arteriography reveals the nidus and the nature of collateral vascular structures and provides access for endovascular therapy. Because of the potential for severe intraoperative hemorrhage and cosmetic and functional deficits, treatment is problematic. Superselective embolization is important in obliterating the vascularity and is an important adjunct to complete surgical resection. Reconstructing the defects is challenging, and the use of tissue expansion and free tissue transfer promises to improve cosmetic and functional outcomes.