K Arcot

Subclavian steal syndrome due to dialysis fistula corrected with subclavian artery stenting

Consider stenting of the proximal subclavian artery to correct symptomatic subclavian steal syndrome due to dialysis arteriovenous fistula.

E-046 Procedural Efficiency of the Streamlined Launchpad Stroke Admission Paradigm – A Single Center Experience

Introduction Time remains a crucial factor in stroke progression. Rapid and complete revascularization has been well correlated with favorable clinical outcome in patients with acute ischemic stroke secondary to large vessel occlusion. To mitigate the deleterious effects due to treatment delay, an initiative has been implemented to shorten the time for patient processing, expediting LVO patients for immediate intervention. The Launchpad protocol was established to ensure admitting stroke patients are triaged quickly and accurately identified in order to reduce time from arrival to intervention, and overall to revascularization. Herein, we assess the efficacy of the Launchpad paradigm in triaging presenting stroke patients. Methods A retrospective review of the stroke database was conducted between September 2014 and January 2016, 3 months prior and 13 months post Launchpad implementation. Prior to Launchpad, patients presenting with stroke were triaged through the traditional Emergency Department (ED) pathway. Through Launchpad, incoming patients bypass the traditional ED pathway and are taken straight for a CT scan by a dedicated stroke team. A CT scan positive for LVO and penumbral tissues will permit patients to continue through the Launchpad pathway for further evaluation and subsequent intervention. Time differences during patient triage before and after Launchpad initiation are assessed to determine the efficiency of this paradigm. Results In total, 764 patients were identified in the retrospective analysis, 137 were admitted prior, and 627 were admitted post Launchpad implementation. In the pre-Launchpad cohort, the median time from admission to CT imaging was 20 minutes. Patients under the Launchpad paradigm showed a reduction in time from presentation to imaging of 5 minutes (p = 0.0004). An increase in efficiency by roughly 25% to CT was observed following Launchpad implementation. Conclusion The streamlined stroke activation Launchpad protocol demonstrated an increased speed in patient admission and significant reduction in time from presentation to CT scan. This significant improvement in processing time allowed for an increased number of patients to meet the therapeutic window for IV tPA eligibility. A prospective trial will strengthen the current finding and support the implementation of this paradigm amongst other stroke centers. Disclosures K. Sivakumar: None. S. Feuerwerker: None. D. Turkel-Parrella: None. A. Tiwari: None. J. Farkas: None. K. Arcot: None.

E-088 A Follow-up to Transradial Access for Acute Interventional Stroke Therapy – A Feasibility Study

Introduction Interventional stroke therapies are quickly becoming the new standard of care for acute large vessel occlusions. Stentrievers and aspiration catheters, while significantly improving recanalization rates, have increased the need for better catheter tracking and stable positioning within the neurovasculature. Difficulties in accessing the target vessel occlusion results in delays and a potential for poor outcome. The main intra-procedural cause for treatment delay and failure-to-treat includes unfavorable vascular anatomy. Type III or bovine aortic arch, extreme tortuosity, aortic aneurysms or severe peripheral vascular disease presents challenging obstacles in access. These anatomical abnormalities can make safe and timely transfemoral access difficult, even impossible at times. Alternative access modes, including transradial access, have proven effective in cardiovascular intervention and may provide advantages in circumventing tortuous vascular anatomy. This modality has been adapted for access in stroke intervention; herein, we present additional results from our previous experience with transradial access for endovascular stroke therapy. Methods A retrospective review of our stroke database was conducted between January 2013 to February 2016 to identify all patients treated endovascularly through transradial access both as first or second intention. The primary outcome of this study measured the success of radial access in ischemic stroke therapy. Secondary outcome evaluated procedural time between cohorts where radial access was primary versus secondary, and procedural adverse events. Results In total, 34 patients were identified, 17 were treated transradially as primary, 16 as secondary, and 1 was a tertiary attempt; the median age was 86 years [IQR 74–90]. In patients where radial access was first intentions, the median time from puncture to clot engagement was 69 minutes [IQR 28.5–78] (mean = 70.7 ± 52.4), with successful revascularization achieved in 86.7% (13/15) of patients. Notably, one patient was approached via primary radial access, however resorted to a transfemoral approach; successful revascularization to mTICI 2 c was achieved. As may be expected, in patients where radial access second intention, time to clot engagement was 91 minutes [IQR 51.5–125.5] (mean = 115.6 ± 53.8) from initial attempts; however, from secondary transradial attempts, median time was 44 minutes [14.0–77.0] (mean = 52.7 ± 46.3). The median time difference between initial puncture to radial access rescue therapy was 14 minutes [IQR 2–46.5] (mean 35.7 ± 52.0). Success was achieved in 70.6% (12/17) of cases in this cohort. Overall, successful revascularization was achieved in 78.1% (25/32) of patients; mTICI scores were not available in 2 patients. There were 4 peri-procedural complications; however, none were considered related to radial access. Conclusion While femoral access remains the standard operating procedure for endovascular intervention of acute ischemic stroke, in patients with tortuous vascular anatomy, or having severe femoral disease, access via transfemoral is discouraged. Results from our study demonstrate that radial access is a safe and promising alternative, both as primary and rescue attempts. In an effort to reduce overall procedural time, radial access should be considered for qualified patients. A larger sample size would better validate the present findings. Disclosures J. Farkas: None. N. Farkas: None. S. Feuerwerker: None. A. Tiwari: None. D. Turkel-Parrella: None. K. Arcot: None. K. Sivakumar: None.

E-093 Contraindications for Radial Access in Endovascular Therapy of Acute Ischemic Strokes

Introduction Alternatives to transfemoral access for acute mechanical thrombectomy have been reported and include direct carotid puncture, brachial artery access, and transradial access. This experience is typically based on a rescue scenario where a transfemoral approach is not feasible or has resulted in failure. Large trials have shown the safety of transradial access for coronary intervention with improved morbidity and mortality rates when compared to transfemoral access for cardiology procedures. When considering an alternative access for difficult interventional stroke therapies a primary consideration for using transradial access should be deliberated. This modality has been adapted for ischemic stroke intervention at several centers including our own. However effective, there are instances in which this modality is ineffective or proves difficult to succeed and should be approached with careful consideration. Methods All patients seeking endovascular therapy secondary to large vessel occlusions and treated by means of radial artery puncture at our center with documented reperfusion outcome were retrospectively reviewed for analysis. In brief, initial consideration for radial approach requires an assessment of coronary vessel tortuosity through CTA. If qualified, a modified Allen’s test is thus performed to determine vascularity and eligibility for radial access. Following artery puncture, a microwire is advanced in adjunct to a 6–7 F sheath, typically a Neuron MAX 088. In cases involving severe aortic arch, a CLARET technique is used, employing the aortic arch and valve to form a loop allowing for access into the more distal neuroanatomy. Once the thrombus is visualized, thrombectomy is carried out in the usual fashion. We identify cases wherein transradial access was employed, either as initial or secondary intentions, with unsuccessful clot engagement. Results A total of 32 patients met criteria in a retrospective review of our database. Reperfusion to mTICI 2 b/3 was achieved in 78.1% (25/32) of cases. Of the 7 cases unsuccessfully treated through radial access; difficulties in revascularization as specifically relating to this modality were observed in 4 cases. Radial puncture was not attempted in 2 cases due to extreme vessel tortuosity. In the remaining 2 cases wherein transradial axis was attempted, thrombus engagement was unsuccessful, either due to physiological morphology or to the upstream distal location of the thrombus. Conclusion An inherent limitation of transradial access is the restriction to a 6–7 F catheter; however other factors must be considered when identifying cases amenable to radial access. These factors include extreme tortuosity, which not only presents a challenge for radial access, but for all access modalities, and patient height. Patients of above average height or have distal occlusions present a true challenge to the efficacy of radial access as current catheters are limited in length, and thus unable to reach the desired destination. These contraindications are important factors when considering this method of approach, but technological advances in this field may overcome some or all of these limitations. Disclosures K. Sivakumar: None. S. Feuerwerker: None. A. Tiwari: None. D. Turkel-Parrella: None. K. Arcot: None. J. Farkas: None.

Oxford Textbook of Vertigo and Imbalance (Book)

Dizziness and falls are ubiquitous and debilitating complaints that plague all ages but are particularly nocuous to the elderly. Most of us, however, tackle this problem with a perfunctory understanding of the underlying mechanisms, not due to any lack of enthusiasm but due to the labyrinthine nature of the multifarious systems that keep the habitually erect human from becoming unpleasantly well-acquainted with the terrain below.

E-025 Initial Multicentre Experience Using the Penumbra 5Max,4MAX and 3MAX Reperfusion Catheters in Acute Stroke Therapy

Purpose The Penumbra MAX System (5MAX, 4MAX, and 3MAX) refers to a new generation of reperfusion catheters with a larger, tapered lumen and new material composition in the distal end designed to enhance aspiration efficiency with improve trackability. Results from a retrospective multicentre study with the Penumbra System 5 MAX, 4MAX and 3MAX reperfusion catheters in acute stroke patients with large vessel occlusion are reported. Methods A retrospective case-review of 22 consecutive acute ischaemic stroke cases from July 2012 through March 2013 treated by the Penumbra System (5 MAX, 4MAX and 3MAX) was performed. The case experience from three institutions was collected in the initial months after the device was released. Results are reported from cases which involved occlusions in the ICA (n=6), proximal MCA M1 (n=10), distal MCA M2 (n=3) and vertebrobasilar arteries (n=3). Results Prior to intervention, all patients presented with TICI 0 or 1. Successful revascularisation was primarily achieved in 86.3% (Tici 2b & Tici 3 ) using the Penumbra System with 5 MAX, 4MAX and 3MAX reperfusion catheters. Mean age was 71.45 ± 14.4 years; median baseline NIHSS score was 20.5 ± 3.96. In 1 patient, embolisation of new territory was found and treated by IA rtPA. One case of intracerebral haemorrhage (ICH) was noted with haemorrhage in a previously unaffected region, possibly secondary to IV rtPA treatment. Conclusion Early clinical experience suggests that the 5 MAX, 4MAX and 3MAX appear to have improved aspiration efficiency and tracking. Follow-up data and additional cases are critical in confirming these initial results. Disclosures J. Farkas: None. K. Arcot: None. R. Kumar: None. J. Delbrune: None. N. Papamitsakis: None. Y. Margulis: None. D. Walzman: None. S. Dash: None. K. Levin: None. S. Azhar: None.

E-044 The Penumbra 5MAX, 4MAX and 3MAX Reperfusion Catheters in Treatment of Acute Ischaemic Stroke: Initial Clinical Experience

Introduction/Purpose The new material composition and larger, tapered lumen in the distal end of the novel Penumbra MAX System reperfusion catheters are designed to enhance aspiration efficiency with improved trackability. Reported herein are results from a retrospective multicentre study with the Penumbra System 5MAX, 4MAX and 3MAX reperfusion catheters in the treatment of acute ischaemic stroke secondary to large vessel occlusion. Materials and Methods A retrospective case-review of 19 consecutive acute ischaemic stroke cases treated with the Penumbra System either as a standalone device or in combination: 5MAX (n=8), 4MAX (n=6) and 3MAX (n=8), from July 2012 through December 2012 was undertaken. Clinical experience at 3 institutions was collected and reported in the first six months after device release. Occlusions were located in the MCA M1and M2 (n=11), ICA and ICA/MCA (n=6), and vertebrobasilar arteries (n=2). Results Eighteen of 19 cases (94.7%) were successfully recanalised to TICI 2 and 3 using the Penumbra MAX System. Complete revascularisation to TICI 3 was achieved in 16 of 19 (84%). The mean patient age was 70.3 ± 13.9 years; the median NIHSS score at presentation was 19 (15 to 29). All patients presented with TICI scores of 0 or 1. At discharge, the median NIHSS score was 14 (1 to 29). One death due to cardiac arrest occurred at 15 days post-procedure. In one patient, stroke in a new territory was observed and treated with IA rtPA. One ICH was found in a previously unaffected region, possibly secondary to IV rtPA therapy. Conclusion Early multicentre experience indicates that the 5MAX, 4MAX and 3MAX reperfusion catheters have enhanced aspiration efficiency and trackability. Follow-up studies will be required to verify these findings. Disclosures J. Farkas: None. K. Arcot: None. D. Walzman: None. R. Kumar: None. J. Delbrune: None. N. Papamitsakis: None. Y. Margulis: None. S. Dash: None. K. Levin: None. S. Azhar: None.