Mark Bain

The versatile distal access catheter: The Cleveland clinic experience

BACKGROUND:Vascular access is fundamental to any endovascular intervention. Concentric Medical has developed the Outreach Distal Access Catheter (DAC), which affords stable access at the target vessel modulating the forces at play within the thrombectomy device complex. The DAC is a device with novel access characteristics useful in a host of other types of clinical scenarios. OBJECTIVE:To review our experience with the DAC family of devices, the theory, and method of use. METHODS:A retrospective review of all cases in which the DAC was used during the period 2008 to 2010 was conducted and the cases classified by indication. Catheter-related complications were recorded. The use of the DAC in a variety of settings including intracranial stenting, aneurysm coil embolization, and arteriovenous malformation embolization is described. RESULTS:The DAC was used in 103 procedures performed in 93 patients between August 2008 and February 2010. Indications included acute stroke, treatment of intracranial atherosclerosis, vasospasm therapy, arteriovenous malformation embolization, and aneurysm embolization. In those procedures, 113 catheters were used. No complications directly attributable to DAC use were identified. CONCLUSION:The DAC is useful for gaining access to the cerebral vasculature, especially in patients with significant tortuosity or when re-access of distal vasculature is required multiple times.

Posterior circulation flow diversion: a single-center experience and literature review

Background Flow diverters have been used predominantly for large anterior circulation aneurysms. Data on the safety and efficacy of this treatment for posterior circulation aneurysms are limited. Objective To present our posterior circulation flow diverter experience, outcomes and morbidity in comparison with recent studies. Methods A retrospective chart and imaging review of six patients with seven aneurysms in posterior circulation vessels, treated with flow diverter technology was carried out. A literature review was performed using standard online search tools. Results We included five saccular and two fusiform posterior circulation aneurysms. An average of two flow diverters was placed for each patient. Adjunctive coiling was used in three cases. Follow-up at an average of 14.5 months showed complete angiographic occlusion in 4 (57.1%) cases, including one patient with in-stent thrombosis and major brainstem stroke at 4.5 months, a week after self-discontinuing dual antiplatelet therapy. Two other patients developed small periprocedural strokes but had excellent recovery. One death occurred 18 months after the initial procedure. No aneurysm rupture or parenchymal hemorrhage was seen. Overall, 5 (71%) cases, all with saccular aneurysms, had good clinical outcome (modified Rankin score (mRS) 0–1). Fusiform basilar aneurysms had markedly worse outcomes (mRS 5 and 6). Our literature review yielded six other studies with 100 additional patients. Overall, good outcome was seen in 74.3%, with a 12.3% average mortality and 11% permanent neurologic deficit rate. Complete occlusion varied from 43% to 100%. Conclusions Flow diversion may be a possible treatment in carefully selected patients with high-risk atypical posterior circulation aneurysms, with poor natural history and no optimal treatment strategy. Symptomatic and fusiform large aneurysms appear to carry the highest risk. Further studies are necessary to assess the role of flow diversion in the posterior circulation.

Addition of Hyperacute MRI Aids in Patient Selection, Decreasing the Use of Endovascular Stroke Therapy

Background and Purpose— The failure of recent trials to show the effectiveness of acute endovascular stroke therapy (EST) may be because of inadequate patient selection. We implemented a protocol to perform pretreatment MRI on patients with large-vessel occlusion eligible for EST to aid in patient selection. Methods— We retrospectively identified patients with large-vessel occlusion considered for EST from January 2008 to August 2012. Patients before April 30, 2010, were selected based on computed tomography/computed tomography angiography (prehyperacute protocol), whereas patients on or after April 30, 2010, were selected based on computed tomography/computed tomography angiography and MRI (hyperacute MRI protocol). Demographic, clinical features, and outcomes were collected. Univariate and multivariate analyses were performed. Results— We identified 267 patients: 88 patients in prehyperacute MRI period and 179 in hyperacute MRI period. Fewer patients evaluated in the hyperacute MRI period received EST (85 of 88, 96.6% versus 92 of 179, 51.7%; P<0.05). The hyperacute-MRI group had a more favorable outcome of a modified Rankin scale 0 to 2 at 30 days as a group (6 of 66, 9.1% versus 33 of 140, 23.6%; P=0.01), and when taken for EST (6 of 63, 9.5% versus 17 of 71, 23.9%; P=0.03). On adjusted multivariate analysis, the EST in the hyperacute MRI period was associated with a more favorable outcome (odds ratio, 3.4; 95% confidence interval, 1.1–10.6; P=0.03) and reduced mortality rate (odds ratio, 0.16; 95% confidence interval, 0.03–0.37; P<0.001). Conclusions— Implementation of hyperacute MRI protocol decreases the number of endovascular stroke interventions by half. Further investigation of MRI use for patient selection is warranted.

Initial Experience Using the 5MAX™ ACE Reperfusion Catheter in Intra-arterial Therapy for Acute Ischemic Stroke

Objectives The 5MAX ACE is a new large bore aspiration catheter available for vessel recanalization for treatment of acute ischemic stroke (AIS). We report our initial experience with its use. Methods A retrospective analysis of patients undergoing intra-arterial therapy for AIS using the 5MAX ACE reperfusion catheter at our institution was performed. Patient demographics, clinical characteristics and procedural data were obtained from chart review. Successful recanlization was defined as achievement of Thrombolysis in Cerebral Infarction score (TICI) 2b-3 and time to recanalization was defined as time from groin puncture to achievement of at least TICI 2b recanalization. Results The 5MAX ACE was used in 15 patients from July-October 2013. Direct aspiration was used as the primary technique in 10/15 (67%) patients. Out of these, aspiration alone was sufficient for recanalization in 3 (20%) patients. In the remaining 7 (47%) patients, additional devices were used. In 5/15 (33%) patients, combined aspiration/stentriever thrombectomy using Solitaire™ (3/5 patients) and Penumbra 3D Separator™ (2/5 patients) were used as the primary technique. Successful recanlization (TICI 2b-3) was achieved in 11/15 (73%) patients. Average time from groin puncture to successful recanalization was 46 +/- 30 minutes (range 14-98 minutes). There were no procedural complications. Conclusion The 5MAX ACE is a useful recanalization tool, either by direct aspiration or combined stentriever/aspiration. It may be most advantageous with large clots in the internal carotid artery. The potential for effective and faster recanalization using this device alone or in combination may be a good topic for future study.

Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis

Background Cerebral angiography remains the gold standard for the detection of mycotic aneurysms, and it has been estimated that ruptured mycotic aneurysms result in 5% of the neurological complications of patients with infective endocarditis (IE). Objective To determine the diagnostic yield of cerebral angiography in the above patient population and to assess patient factors that might suggest greater or lesser utility. Methods We retrospectively reviewed 168 patients who underwent cerebral angiography with a diagnosis of IE or infected left ventricular assist device at the Cleveland Clinic between January 2003 and March 2010 in accordance with institutional review board guidelines. Chart and imaging review was performed. Results 15/168 patients (8.9%) had mycotic aneurysms; 93.3% (14/15) of the patients with mycotic aneurysms presented with CNS hemorrhage and 66.7% (10/15) had acute ischemic findings. Of the 15 patients with mycotic aneurysms on angiography, seven underwent CT angiography and six underwent MR angiography, which showed mycotic aneurysms in three (42.9%) and two cases (one of which was questionable; 33.3%), respectively. Conclusions Patients with IE or similar sources of central bacterial emboli are prone to neurovascular complications. Approximately 9% of patients with IE at our institution who undergo cerebral angiography have mycotic aneurysms. Presentation with hemorrhage appears to be more predictive of aneurysm, as approximately 22% of patients with IE and hemorrhage were found to have an aneurysm compared with only 1% when hemorrhage was absent. Thus, patients with IE presenting with intracranial hemorrhage should undergo vascular imaging, preferably with cerebral angiography.

Preclinical safety validation of a stabilized viral vector direct injection approach to the cervical spinal cord.

The current lack of a validated intraspinal delivery approach precludes translation of promising cell or viral‐based therapeutics for treatment of varied spinal cord afflictions. We have developed a stabilized cervical microinjection platform with the intent of precise delivery to intraspinal sites of interest. Nine 30–40 kg female swine underwent coordinate‐based microinjection AAV2‐GFP at three injected volumes (10, 25, and 50 μL (n= 3/group)) and matched infusion rates (1.0, 2.5, and 5.0 μL/min) over a period (t= 10 minutes). Preliminary validation is provided by behavioral and targeting data demonstrating safe delivery of a viral vector carrying a fluorescent reporter gene to the cervical spinal cord ventral horn.

Double-barrel stent reconstruction of a symptomatic fusiform basilar artery aneurysm: case report.

BACKGROUND AND IMPORTANCE:Giant fusiform aneurysms of the basilar artery are associated with a high rate of morbidity and mortality. Treatment of these lesions can be difficult, especially when there are poor anatomic collaterals such as posterior communicating arteries. These lesions often have no acceptable treatment. The authors present a case of a patient with a symptomatic, fusiform basilar artery aneurysm successfully treated with a side-by-side (double-barrel), telescoping stent construct. CLINICAL PRESENTATION:A 56-year-old man presented with chief concerns of dysarthria and left-sided hemiparesis. MRI and conventional catheter-based angiography revealed a dolichoectatic basilar artery with 3 large fusiform aneurysms throughout its length. Flow through the patients aneurysm was successfully reduced with a side-by-side stent construct and coiling of the proximal aneurysm dilation. The patient experienced stabilization of his ischemic events and neurologic recovery. A total of 6 Neurform-2 4.5 × 30-mm stents were navigated and positioned from the proximal posterior cerebral arteries to the distal vertebral arteries in a side-by-side (double-barrel), telescoping manner. These were deployed simultaneously by 2 operators to oppose the stent struts as well as the arterial wall. Next, the proximal aneurysmal dilation was coiled to near occlusion. Successful flow redirection and aneurysm thrombosis was observed. CONCLUSION:A novel, endovascular stenting technique for successfully treating symptomatic, giant basilar artery aneurysms is presented. This patient at 4 months was living independently with no further neurologic events or decline.

Successful Recanalization of a Septic Embolus with a Balloon Mounted Stent after Failed Mechanical Thrombectomy

Cardiac emboli are a feared complication for patients with left ventricular assist devices (LVAD). Septic emboli are rare but carry a poor prognosis in the setting of large artery occlusion. We report the case of a 24‐year‐old woman who presents with a left internal carotid artery terminus occlusion secondary to a septic emboli from a LVAD. The patient was not a candidate for intravenous thrombolytics due to an elevated international normalized ratio, and thus was taken for intra‐arterial treatment. Initial treatment with mechanical thrombectomy and balloon angioplasty was not successful; thus, a balloon‐mounted coronary stent was placed to achieve successful recanalization. Fragments of thrombus on the mechanical thrombectomy device revealed gram‐positive bacilli on gram stain. Patients with large artery occlusion due to a septic embolus can be successfully treated with endovascular therapies in select patients.

Targeted extracranial-intracranial bypass with intra-aneurysmal administration of indocyanine green: Case report

BACKGROUND AND IMPORTANCE: Early origin of the middle cerebral artery M2 segment is a normal variant. When such a vessel is occluded proximally, the parenchyma distal to the vessel may become ischemic. Targeted extracranial to intracranial bypass to such a specific branch may preserve perfusion to the end organ. We describe the use of intra-aneurysmal injection of indocyanine green to identify a target middle cerebral artery branch (MCA) for bypass, immediately followed by proximal parent vessel sacrifice via endovascular embolization. CLINICAL PRESENTATION: A 45-year-old woman presented to an outside hospital with headaches. Magnetic resonance imaging revealed a giant aneurysm of the right MCA. The aneurysm gave rise to an M2 branch that supplied the right anterior frontal operculum, as well as the anterolateral portion of the superior temporal gyri. Balloon test occlusion was nondiagnostic because of the territory involved, and the risk of sizable infarction after vessel sacrifice was thought to be high. Craniotomy and targeted extracranial to intracranial bypass to an M4 opercular branch was performed with intra-aneurysmal injection of indocyanine green. In our combined endovascular/open cerebrovascular suite, an opercular MCA branch that fluoresced during the first-pass arterial circulation of indocyanine green was identified, and a superficial temporal artery to MCA bypass was performed. Angiographic verification of bypass patency was confirmed, followed by embolic occlusion of the giant aneurysm with preservation of flow to the parenchyma at risk through the bypass. CONCLUSION: Targeted bypass to distal branches is feasible with intra-arterial and intra-aneurysmal injection of indocyanine green, allowing confident preservation of blood supply to areas distal to the sacrificed vessel.

Bow hunter's syndrome secondary to bilateral dynamic vertebral artery compression.

Bow hunters syndrome is a condition in which vertebrobasilar insufficiency is resultant from head rotation, clinically manifested by presyncopal sensation, syncope, dizziness, and nausea. It is usually diagnosed clinically, with supporting vascular imaging demonstrating an occluded or at the very least compromised unilateral vertebral artery, while the dominant vertebral artery remains patent in the neutral position. Dynamic imaging is utilized to confirm the rotational compression of the dominant vertebral artery. We present the rare case of a patient with typical Bow hunters symptoms, bilaterally patent vertebral arteries on neutral imaging, and bilateral compromise with head rotation. Our patient underwent posterior decompression of the culprit atlanto-axial transverse foramen and subaxial cervical fusion, with resolution of his symptoms. Our patient exemplifies the possibility of bilateral dynamic vertebral artery occlusion. We show that Bow hunters syndrome cannot be ruled out in the setting of bilaterally patent vertebral arteries on neutral imaging and that severe cervical spondylosis should impart further clinical suspicion of this unusual phenomenon.