Richard A. Haas

Percutaneous Revascularization of Complex Iliac Artery Stenoses and Occlusions with Use of Wallstents: Three-year Experience

PURPOSE To assess the outcome of percutaneous placement of Wallstents for treatment of hemodynamically significant diffuse stenoses (> 3 cm in length), chronic occlusions, failed angioplasty procedures, and flow-limiting dissection in the iliac arteries. MATERIALS AND METHODS Lesions in 94 iliac limbs were treated in 66 patients. Indications for stent placement included claudication in 49 limbs and limb-threatening ischemia in 45. Forty-two limbs were treated for diffuse disease, 39 for chronic occlusion, nine for failed angioplasty, and four for flow-limiting dissection. RESULTS Technical success was achieved in 86 of 94 limbs (91%), with major complications in 9% of patients. One death occurred within 30 days (not procedure-related). Ankle-brachial indexes improved from 0.51 +/- 0.24 to 0.76 +/- 0.22 (P < .001). Eighty-five percent demonstrated improvement under Rutherford criteria. Follow-up was obtained up to 38 months (mean, 14 months +/- 8). Cumulative primary patency rates were 78% at 1 year and 53% at 2 and 3 years (standard error 10%). Secondary patency rates were 86% at 1 year and 82% up to 32 months (standard error > 10% after 32 months). No significant decrease in mean ankle-brachial index was observed during follow up. No difference in primary patency was observed based on lesion type, symptom severity, lesion location, or runoff status. The limb salvage rate for patients with limb-threatening ischemia was 98% at a mean follow-up of 14 months +/- 7. CONCLUSIONS Technical success and complication rates for percutaneous iliac artery revascularization with use of Wallstents are favorable, symptoms improved in the majority of patients, and excellent secondary patency can be achieved. With use of Wallstents, most patients with iliac artery insufficiency as a result of long-segment disease or chronic occlusions can be treated percutaneously.

Quality of life and exercise performance after aortoiliac stent placement for claudication

PURPOSE To determine the effect of aortoiliac stent placement on walking ability and health-related quality of life (QOL) for elderly individuals with moderate to severe intermittent claudication. MATERIALS AND METHODS A prospective single-center study was performed in 35 consecutive patients (46 symptomatic limbs) with intermittent claudication and aortoiliac insufficiency (mean age+/-SD, 61.1 years+/-9.5). Baseline and follow-up data to 12 months included clinical status, ankle-brachial index (ABI), exercise performance according to a standardized treadmill exercise protocol, and self-reported health-related QOL according to the Walking Impairment Questionnaire (WIQ) and the Short Form 36 (SF-36). RESULTS Comparing baseline with 12-month data, mean ABI significantly improved from 0.64+/-0.15 to 0.89+/-0.19 (P<.01). Similarly, mean initial claudication duration improved from 1.7 minutes+/-1.0 to 4.7 minutes+/-3.3 and maximum walking duration on the treadmill test improved from a mean of 3.3 minutes+/-1.8 to 8.7 minutes+/-4.4. All WIQ subscales showed significant improvement, and the SF-36 physical component scale as well as subscales of physical functioning, bodily pain, role physical, and vitality showed significant improvement. There was no 30-day mortality. Complications in the perioperative period that required treatment were observed in three patients (9%), but surgery was not required for any complications. Importantly, urgent or emergent surgery was not required for any complication and no permanent disability related to complications occurred. CONCLUSIONS A high technical success rate (97%) and low complication rate were observed. Exercise performance and health-related QOL results improved significantly after stent placement. Revascularization with stent placement should be strongly considered in addition to conservative management for moderate to severe claudication with aortoiliac obstruction. A randomized clinical trial would be needed to gauge the relative effectiveness of stent implantation and conservative therapy.

Continuous aspiration prior to intracranial vascular embolectomy (CAPTIVE): a technique which improves outcomes

Background Modern stent retriever-based embolectomy for patients with emergent large vessel occlusion improves outcomes. Techniques aimed at achieving higher rates of complete recanalization would benefit patients. Objective To evaluate the clinical impact of an embolectomy technique focused on continuous aspiration prior to intracranial vascular embolectomy (CAPTIVE). Methods A retrospective review was performed of 95 consecutive patients with intracranial internal carotid artery or M1 segment middle cerebral artery occlusion treated with stent retriever-based thrombectomy over an 11-month period. Patients were divided into a conventional local aspiration group (traditional group) and those treated with a novel continuous aspiration technique (CAPTIVE group). We compared both early neurologic recovery (based on changes in National Institute of Health Stroke Scale (NIHSS) score), independence at 90 days (modified Rankin score 0–2), and angiographic results using the modified Thrombolysis in Cerebral Ischemia (TICI) scale including the TICI 2c category. Results There were 56 patients in the traditional group and 39 in the CAPTIVE group. Median age and admission NIHSS scores were 78 years and 19 in the traditional group and 77 years and 19 in the CAPTIVE group. Median times from groin puncture to recanalization in the traditional and CAPTIVE groups were 31 min and 14 min, respectively (p<0.0001). While rates of TICI 2b/2c/3 recanalization were similar (81% traditional vs 100% CAPTIVE), CAPTIVE offered higher rates of TICI 2c/3 recanalization (79.5% vs 40%, p<0.001). Median discharge NIHSS score was 10 in the traditional group and 3 in the CAPTIVE group; this difference was significant. There was also an increased independence at 90 days (25% traditional vs 49% CAPTIVE). Conclusions The CAPTIVE embolectomy technique may result in higher recanalization rates and better clinical outcomes.

Incidence of extrinsic compression of the internal jugular vein in unselected patients undergoing CT angiography.

BACKGROUND AND PURPOSE: Little is known about how commonly the internal jugular vein is compressed by extrinsic structures in the upper neck. The purpose of this paper was to identify the frequency and cause of external compression of the superior segment of the internal jugular vein. MATERIALS AND METHODS: Retrospective review of CT angiograms of the neck was performed in 108 consecutive patients. Axial source images were evaluated for moderate (>50%) or severe (>80%) stenosis of the internal jugular vein on the basis of external compression. The cause of extrinsic compression was also recorded. In cases with stenosis, the presence of ipsilateral isoattenuated collateral veins was recorded and considered representative of collateral flow. RESULTS: Moderate stenosis was seen in 33.3% of right and 25.9% of left internal jugular veins. Severe stenosis was seen in 24.1% of right and 18.5% of left internal jugular veins. The most common causes of extrinsic compression included the styloid process and the posterior belly of the digastric muscle. In patients with severe internal jugular vein stenosis, 53.8% of right sides and 55% of left sides had associated condylar collaterals. CONCLUSIONS: Extrinsic compression of the superior segment of the internal jugular vein is a common finding in unselected patients, often caused by the styloid process or the posterior belly of the digastric muscle. Presence of severe stenosis is not universally associated with collateral formation.

Distal anterior choroidal artery aneurysm : Intraoperative localization and treatment

Distal anterior choroidal artery aneurysms with intraventricular hemorrhage are rare and difficult to treat. We report the case of a 46-year-old woman with a left distal anterior choroidal artery aneurysm presenting as a typical subarachnoid hemorrhage from which she had no focal neurological signs. Because the aneurysm was located within the dominant deep temporal lobe, we used intraoperative computed tomography to guide a probe to the aneurysm to allow minimal dissection. This is the first report of a successfully treated distal anterior choroidal artery aneurysm. Reports of this unusual aneurysm and methods of approaching deep temporal lesions are reviewed.

Association of a Primary Stroke Center Protocol for Suspected Stroke by Large-Vessel Occlusion With Efficiency of Care and Patient Outcomes.

Importance While prehospital triage to the closest comprehensive stroke center (CSC) may improve the delivery of care for patients with suspected emergent large-vessel occlusion (ELVO), efficient systems of care must also exist for patients with ELVO who first present to a primary stroke center (PSC). Objective To describe the association of a PSC protocol focused on 3 key steps (early CSC notification based on clinical severity, vessel imaging at the PSC, and cloud-based image sharing) with the efficiency of care and the outcomes of patients with suspected ELVO who first present to a PSC. Design, Setting, and Participants In this retrospective cohort study, 14 regional PSCs unfamiliar with the management of patients with ELVO were instructed on the use of the following protocol for patients presenting with a Los Angeles Motor Scale score 4 or higher: (1) notify the CSC on arrival, (2) perform computed tomographic angiography concurrently with noncontract computed tomography of the brain and within 30 minutes of arrival, and (3) share imaging data with the CSC using a cloud-based platform. A total of 101 patients were transferred from regional PSCs to the CSC between July 1, 2015, and May 31, 2016, and received mechanical thrombectomy for acute ischemic stroke. The CSC serves approximately 1.7 million people and partners with 14 PSCs located between 6.4 and 73.6 km away. All consecutive patients with internal carotid artery or middle cerebral artery occlusions transferred over an 11-month period were reviewed, and they were divided into 2 groups based on whether the PSC protocol was partially or fully executed. Main Outcomes and Measures The primary outcomes were efficiency measures including time from PSC door in to PSC door out, time from PSC door to CSC groin puncture, and 90-day modified Rankin Scale score (range, 0-6; scores of 0-2 indicate a good outcome). Results Although 101 patients were transferred, only 70 patients met the inclusion criteria during the study period. The protocol was partially executed for 48 patients (68.6%) (mean age, 77 years [interquartile range, 65-84 years]; 22 of the 48 patients [45.0%] were women) and fully executed for 22 patients (31.4%) (mean age, 76 years [interquartile range, 59-86 years]; 13 of the 22 patients [59.1%] were women). When fully executed, the protocol was associated with a reduction in the median time for PSC arrival to CSC groin puncture (from 151 minutes [95% CI, 141-166 minutes] to 111 minutes [95% CI, 88-130 minutes]; P < .001). This was primarily related to an improvement in the time from PSC door in to door out that reduced from a median time of 104 minutes (95% CI, 82-112 minutes) to a median time of 64 minutes (95% CI, 51-71.0 minutes) (P < .001). When the protocol was fully executed, patients were twice as likely to have a favorable outcome (50% vs 25%, P < .04). Conclusions and Relevance When fully implemented, a standardized protocol at PSCs for patients with suspected ELVO consisting of early CSC notification, computed tomographic angiography on arrival to the PSC, and cloud-based image sharing is associated with a reduction in time to groin puncture and improved outcomes.

StarClose Vascular Closure Device: Safety and Efficacy of Deployment and Reaccess in a Neurointerventional Radiology Service

BACKGROUND AND PURPOSE: Obtaining safe and effective closure of the femoral access site following neurointerventional procedures can sometimes be challenging, especially in patients on anti-coagulation or anti-platelet therapy. The purpose of this study was to evaluate the safety and efficacy of a novel percutaneous closure device that employs a nitinol clip–mediated extravascular closure strategy following neurointerventional procedures. MATERIALS AND METHODS: We performed a retrospective review of all patients who underwent neurointerventional procedures at our institution between January 1, 2006 and December 31, 2008. We evaluated the safety and efficacy of the StarClose device in patients undergoing first and repeat procedures. Groin complications were classified as self-limited hematoma, hematoma requiring transfusion, other/minor (pseudoaneurysm, infection), and other/major (vascular complication). RESULTS: StarClose device use was attempted in 281 of 352 cases (79.8%) with success reported in 269 cases (95.7%). Minor and major complications occurred in 0.7% and 0.4% of patients, respectively. There was one major vascular complication. Repeat use was performed in 84 patients with 100% success and a 2.3% minor complication rate. Time to reaccess ranged from 1 to 1036 days (mean, 105 days). CONCLUSIONS: The StarClose device achieves rapid and safe femoral arterial closure in patients, both for primary closure and after reaccess.

Antibiotics and Nephrostomy Tube Care: Preliminary Observations Part II. Bacteremia

Bacteriuria occurs after long-term drainage of the kidney. This study was designed to determine if the risk of bacteremia increases at the time of tube or stent change, whether bacteremia correlates with clinical infection, and if prophylactic antibiotics are effective in the prevention of bacteremia. One hundred four tube changes in 74 patients with percutaneous nephrostomy tubes and documented positive urine cultures were studied. Patients were arbitrarily divided into groups receiving and not receiving antibiotics before nephrostomy tube change. Asymptomatic bacteremia was documented in 11 of 104 tube changes (11%). Results of five blood cultures were positive in the group receiving antibiotics, and six cases of bacteremia occurred in the group not receiving antibiotics (P = .96). Routine nephrostomy/stent change can cause frequent, asymptomatic bacteremia in patients with colonization of bacteria in the urinary tract. Antibiotic prophylaxis was unsuccessful in preventing transient bacteremia, a factor that may have implications in patients with underlying valvular heart disease and other patients at risk for bacteremia.

Extensive Thromboembolic Disease of the Hand and Forearm: Treatment with Thrombolytic Therapy

Six patients with extensive hand and forearm thromboembolic disease were treated by means of intraarterial infusion of urokinase, with good clinical results. Four significant complications occurred, including a possible stroke. Embolization of pericatheter thrombus was a possible etiologic factor in this case. Antegrade brachial artery puncture should be used in the setting of prolonged upper extremity thrombolytic therapy to avoid the cerebral vasculature. Thrombolysis is an effective technique for tissue salvage in cases of inoperable hand thrombosis.

Decreasing procedure times with a standardized approach to ELVO cases

Background Embolectomy is the standard of care for emergent large vessel occlusion (ELVO), and needs to be done as quickly as possible for the best possible outcomes. Optimization of workflow and process is certainly paramount. One aspect of this is process improvement to standardize as much as possible the procedure in order to decrease variability among operators, which breeds familiarity for the entire team. Objective To evaluate the impact of a standardized approach to ELVO cases in decreasing times from groin puncture to first deployment of a stent-retriever and final recanalization. Methods A retrospective review of 83 consecutive patients consisting of a pre-standardization phase (group 1) and those after standardization (group 2). The standardization process involved all three neurointerventional radiologists agreeing on a standard approach to the cases and to the equipment to be used. Times from groin puncture to first deployment of the stent-retriever and from puncture to final reperfusion were evaluated. Angiographic outcomes were scored using the Modified Thrombolysis in Cerebral Ischemia (mTICI) score. Complications from intracranial catheter manipulation (such as wire perforation) were also recorded. Clinical outcomes were assessed based on admission and discharge National Institute of Health Stroke Scale score. Results There were 22 patients in group 1 and 61 patients in group 2. Mean times from groin puncture to first deployment were 39.8 min in group 1 and 20 min in group 2, a difference which was statistically significant (p<0.0001). Overall times from puncture to final recanalization were reduced from 68.2 to 37 min, also a statistically significant difference (p<0.001). There were no cases of intraprocedural complications such as wire perforation or subarachnoid hemorrhage. Conclusions A standardized approach to the equipment used and process for ELVO cases at a single institution can dramatically reduce procedure times.