Yingkun He

Perioperative complications of recanalization and stenting for symptomatic nonacute vertebrobasilar artery occlusion.

BACKGROUND Endovascular recanalization and stenting has been used to treat patients with symptomatic nonacute intracranial vertebrobasilar artery occlusion (VBAO) refractory to aggressive medical treatment. This study was performed to analyze the perioperative complications of the procedures. METHODS Between February 2010 and March 2012, 27 consecutive patients (24 men, 3 women; age: 57 ± 10 years) with symptomatic, nonacute intracranial VBAO including 12 basilar artery occlusions and 15 vertebral artery occlusions were collected and retrospectively analyzed. RESULTS The median time between symptom onset and recanalization was 1.5 months (interquartile range [IQR]: 0.7-3.4) and between imaging-documented occlusion and recanalization was 9.5 days (IQR: 6-18 days). Recanalization was achieved in 96% of patients (26/27). Five (5/27; 19%) perioperative complications occurred. Two patients had dissections: 1 dissection resulted in termination of the procedure without successful recanalization, and the other was handled by the placement of 2 stents. There was 1 intraprocedural acute thrombosis that was successfully treated with balloon angioplasty. One patient experienced thrombus disruption and translocation during the procedure: thrombus was dislodged after disruption by the guidewire. There was 1 acute reocclusion after procedure: while recanalization was achieved again, there was no improvement in clinical outcome. CONCLUSIONS This study revealed that recanalization and stenting for nonacute VBAO may be technically feasible but that it is accompanied by a high risk of complication. The causative factors for perioperative complications need future study.

Safety and efficacy of a new prophylactic tirofiban protocol without oral intraoperative antiplatelet therapy for endovascular treatment of ruptured intracranial aneurysms

Background Coil embolization of intracranial aneurysms is being increasingly used; however, thromboembolic events have become a major periprocedural complication. Objective To determine the safety and efficacy of prophylactic tirofiban in patients with ruptured intracranial aneurysms. Methods Tirofiban was administered as an intravenous bolus (8.0 μg/kg over 3 min) followed by a maintenance infusion (0.10 μg/kg/min) before stent deployment or after completion of single coiling. Dual oral antiplatelet therapy (loading doses) was overlapped with half the tirofiban dose 2 h before cessation of the tirofiban infusion. Cases of intracranial hemorrhage or thromboembolism were recorded. Results Tirofiban was prophylactically used in 221 patients, including 175 (79.19%) who underwent stent-assisted coiling and 46 (20.81%) who underwent single coiling, all in the setting of aneurysmal subarachnoid hemorrhage. Six (2.71%) cases of intracranial hemorrhage occurred, including four (1.81%) tirofiban-related cases and two (0.90%) antiplatelet therapy-related cases. There were two (0.90%) cases of fatal hemorrhage, one related to tirofiban and the other related to dual antiplatelet therapy. Thromboembolic events occurred in seven (3.17%) patients (6 stent-assisted embolization, 1 single coiling), of which one (0.45%) event occurred during stenting and six (2.72%) occurred during intravenous tirofiban maintenance. No thromboembolic events related to dual antiplatelet therapy were found. Conclusions Tirofiban bolus over 3 min followed by maintenance infusion appears to be a safe and efficient prophylactic protocol for the endovascular treatment of ruptured intracranial aneurysms and may be an alternative to intraoperative oral antiplatelet therapy, especially in the case of stent-assisted embolization.

Wingspan Stenting for Severe Symptomatic Intracranial Atherosclerotic Stenosis in 433 Patients Treated at a Single Medical Center.

Purpose To investigate the safety and outcome of intracranial stenting for intracranial atherosclerotic stenosis (IAS). Materials and Methods Between July 2007 and April 2013, 433 consecutive patients with IAS >70% underwent intracranial Wingspan stenting, and the data were prospectively analyzed. Results Intracranial stenting was successful in 429 patients (99.1%), and the mean stenosis rate was improved from prestenting (82.3± 7.6)% to poststenting (16.6 ± 6.6)%. During the 30-day perioperative period, 29 patients (6.7%) developed stroke. The total perioperative stroke rate was significantly (P <0.01) higher in the basilar artery area than in others, whereas the hemorrhagic stroke rate was significantly (P <0.05) greater in the middle cerebral artery area than in others. The experience accumulation stage (13%) had a significantly (P <0.05) higher stroke rate than the technical maturation stage (4.8%). Clinical follow-up 6–69 months poststenting revealed ipsilateral stroke in 20 patients (5.5%). The one- and two-year cumulative stroke rates were 9.5% and 11.5%, respectively; the two-year cumulative stroke rate was significantly (P <0.05) greater in the experience accumulation stage (18.8%) than in the technical maturation stage (9.1%). Conclusion Wingspan stenting for intracranial atherosclerotic stenosis is safe and the long-term stroke rate after stenting is low in a Chinese subpopulation.

Management of tandem internal carotid and middle cerebral arterial occlusions with endovascular multimodal reperfusion therapy.

The aim of this study was to evaluate the safety and efficacy of multimodal reperfusion therapy (MMRT) for tandem internal carotid artery and middle cerebral arterial (TIM) occlusions. Cases of TIM occlusion were collected and retrospectively reviewed. The analyzed objects included etiology, sites of tandem occlusion, collateral flow, location and size of infarcts. Combined with mechanical recanalization techniques and its complications, the National Institute of Health Stroke Scale (NIHSS) score and imaging data that was derived pre- and post-procedure were further contrasted. The study enrolled six patients with TIM occlusions. The mean NIHSS score on admission was 17 (range 13–20) and the median time from puncture to recanalization was 141 min (range 60–230). The substantial recanalization rate (Thrombolysis in Cerebral Infarction 2b or 3) was 83.3% and no symptomatic intracerebral hemorrhage was observed. The mean NIHSS score after three days was 14 (range 10–19) and 9 (range 3–17) following discharge. However, one patient died of pulmonary infection one month after discharge. For the five patients who survived, the modified Rankin Scale was evaluated at three months, with scores of 3, 1, 3, 5 and 3, respectively. It is concluded that endovascular therapy for acute TIM occlusions are complex, MMRT may be relatively safe and effective.

Preliminary findings of recanalization and stenting for symptomatic vertebrobasilar artery occlusion lasting more than 24 h: A retrospective analysis of 21 cases

PURPOSE To evaluate the technical feasibility, safety and short-term treatment effects of recanalization and stenting for intracranial symptomatic vertebrobasilar artery occlusion (VBAO) lasting more than 24h. METHODS AND MATERIALS Twenty-one consecutive patients with VBAO refractory to aggressive medical treatment were enrolled into this study and underwent recanalization and stenting. The rate of recanalization was evaluated radiographically and the functional outcome was examined using modified Rankin Scale (mRS) scores. RESULTS Median time between imaging-documented occlusion and endovascular recanalization was 10.5 days (IR, Interquartile Range: 6.5-18); technique success ratio of recanalization was 95.2%. There were 3 periprocedural complications. Median mRS score was 4 (IR, 2.5-5) prior to procedure and 4 (IR, 1-5) at discharge (P<0.05). One stroke and one death occurred within 30 days after recanalization. Mean duration of clinical follow-up was 15.5 months. One transient ischemic attack, one stroke and one death occurred beyond 30-day window. Mean angiographic follow-up was 10.6 months in 10 patients. Four patients developed in-stent restenosis or occlusion, and two of them were symptomatic. Subgroup analyses revealed better functional recovery (lower mRS) in patients with vertebral artery occlusion (VAO) (P<0.05). CONCLUSIONS Endovascular recanalization and stenting for symptomatic VBAO lasting more than 24h were technically feasible and patients with VAO benefited from the treatment with significant functional recovery. However, the complexity of the procedure and high risk of complication should prompt extreme caution.

Curative Transvenous Embolization for Ruptured Brain Arteriovenous Malformations: A Single-Center Experience from China

OBJECTIVE To evaluate feasibility and safety of transvenous embolization for brain arteriovenous malformations (AVMs). METHODS Between November 2016 and August 2017, a transvenous endovascular embolization protocol was implemented at the Henan Provincial Peoples Hospital for consecutive patients with ruptured brain AVMs. Therapeutic decision making was based on Spetzler-Martin grade, brain AVM location, pattern of venous drainage, and angioarchitecture. Transvenous embolization was combined with transarterial support. Complete angiographic obliteration of the nidus was the objective of treatment. RESULTS Among 10 patients with ruptured brain AVMs, 8 were male. Spetzler-Martin grades before transvenous embolization were IV in 3 patients, III in 5 patients, II in 1 patient, and I in 1 patient. Modified Rankin Scale score before the procedure was 0-2 for 6 of 10 patients. Five patients also had deep venous drainage. Arterial blood pressure control and venous pressure cooker technique were used in all 10 patients; 9 patients had immediate angiographic occlusion. Two patients had a ventricular hemorrhage, which did not cause any disability after medical treatment. Seven patients underwent angiography 3-5 months after the procedure, and complete obliteration of the nidus was confirmed. Median clinical follow-up for all 10 patients was 8 months (range, 3-12 months). Epilepsy occurred in 1 patient 3 months after the procedure, and modified Rankin Scale scores for all patients were ≤1. CONCLUSIONS Transvenous embolization of brain AVMs is feasible and may improve cure rates. The safety and long-term effects need further validation.

Transvenous embolization for intracranial arteriovenous malformations: study protocol for a prospective, single-center cohort trial

Background and objectives: In 2010, Nguyen et al. reported a novel method for the treatment of intracranial arteriovenous malformations by transvenous embolization combined with conventional treatment. At present, although the outcome of this approach is generally good, most studies are case reports, and there is a lack of prospective cohort study for assessing the effectiveness of this method. Therefore, in this clinical trial protocol, we will assess the efficacy of transvenous embolization of draining venous unit, with the aim of helping to optimize treatment strategies for patients with intracranial arteriovenous malformations. Design: This is a prospective, single-center cohort study. Methods: We will recruit 190 patients with intracranial arteriovenous malformations from the Department of Intracranial Arteriovenous Malformation, Henan Provincial Peoples Hospital, China. The patients will be assigned to two groups. Participants in the control group (n = 95) will undergo conventional treatment, such as surgery, stereotactic radiosurgery and transarterial embolization. Participants in the trial group (n = 95) will receive transvenous embolization combined with conventional treatment. Outcome measures: The primary outcome measures are stroke or death within 30 days of surgery, and efficacy of treatment at 6 months postoperatively. The secondary outcome measures are the efficacy of treatment at 30 days and 24 months postoperatively, National Institutes of Health Stroke Scale scores, modified Rankin Scale scores at 1, 7 and 30 days and 3, 6, 12, 24 and 36 months postoperatively, and adverse reactions during treatment and follow-up. Discussion: Our study will provide clinical evidence for the rational use of transvenous embolization for intracranial arteriovenous malformations. Ethics and dissemination: This trial has been approved by the Medical Ethics Committee of Henan Provincial Peoples Hospital of China [approval number: 2017 (41)]. This trial was designed in 1 August 2017. Ethics approval was completed in 19 October 2017. This trial was registered in 11 December 2017. The recruitment of participants began in January 2018. The recruitment will be finished in January 2019. Follow-up will be completed in January 2022. Data analysis will be finished in January 2023. Trial registration: This trial had been registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-OOC-17013851). Protocol version (1.0).

Mechanical Recanalization Using Solitaire AB Device for Severe Thromboembolic Events in Endovascular Treatment of Intracranial Aneurysms

IntroductionSevere thromboembolism with complete occlusion of the proximal arteries during or after coil embolization can cause serious neurologic deficits. The study aimed to assess the effectiveness and safety of Solitaire AB device as a rescue therapy for severe thromboembolic complications in the endovascular treatment of intracranial aneurysms.Materials and MethodsBetween February 2013 and April 2016, 1047 intracranial aneurysms treated with endovascular procedures were retrospectively reviewed in our center. Severe thromboembolisms occurred in ten patients and were treated by Solitaire AB device including clot retriever and permanent stent deployment.ResultsThe location of arterial occlusion was distal to the aneurysm rather than the coil/parent artery interface or in-stent area. Four patients had distal thromboembolic events before coil embolization, and six patients had it after coiling. The complete arterial recanalization (TICI 3) was achieved in all patients, and no cerebral hemorrhage was related to the procedure after the rescue therapy. Among these patients with the aforementioned neurovascular procedures, the mean Glasgow Outcome Scale (GOS) score was 4.5 (ranging 3–5) and eight cases had good outcome with a score of GOS 4–5 at discharge, while eight patients presented mRS ≤2 at 3-month follow-up.ConclusionsThese results demonstrate that mechanical recanalization using Solitaire AB device seems to be effective and safe as a rescue therapy for severe thromboembolic events during cerebral aneurysm embolization.

Revascularization with stenting of the nonacute vertebrobasilar artery occlusion

A sub-set of patients with nonacute vertebrobasilar artery occlusion (VBAO) suffers recurrent ischemic events and progressive disability despite intensive medical therapy. Optimal management in these patients is unknown, and there is little literature to guide therapy. Recently, revascularization with stenting has been tried (1,2). However, the efficacy is unsure. We report on 27 patients (24 men, three women; age, 57 10 years) with symptomatic intracranial VBAO beyond 24 h who received revascularization with stenting. The median time between onset of symptoms and revascularization was 1·5 months [interquartile range (IQR), 0·7–3·4], and that between imagingdocumented occlusion and revascularization was 9·5 (IQR, 6–18) days. Successful revascularization, which was defined as Thrombolysis in Myocardial Infarction (3) 2 of antegrade blood flow through the recanalized portion, was achieved in 26 of 27 patients. The median mRSs (modified Rankin Scale) were 4 (IQR, 2–5) 24 h before operation and 3 (IQR, 1–5) six-days after operation (T = 46, P = 0·0016). Five (19%) periprocedural complications occurred. Of them, one caused death, two caused NIHSS (National Institutes of Health Stroke Scale) increase with 3 and 5 scores, and two were solved without new symptoms and NIHSS increase. The latest mean duration of clinical follow-up was 10·5 6·6 months in 27 patients. The median mRS was 2 (IQR, 1–4). The proportion of patients with mRS 2 increased from 27·34% preventive to 61·54%. One transient ischemic attack, two strokes, and two deaths (both died of multiple organ failure) occurred postoperatively. The mean angiographic follow-up was 8·6 3·5 months in nine patients. During this period, two patients developed in-stent restenosis and one reocclusion. Two of them were symptomatic. Our results suggested that revascularization with stenting of nonacute VBAO is technically feasible and probably of benefit in appropriately selected patients. It can prevent from recurrent ischemic event and promote functional recovery, which may be due to the reperfusion of the hemodynamic compromise and neuroplasticity (4) in poststroke brain. However, the high risk of complication should prompt extreme caution.