Citations

Abstract We present a case of tandem stenosis of the great vessels (cervical internal carotid artery [ICA] and brachiocephalic trunk ostium [BTO]) treated with stenting and balloon angioplasty of both lesions under flow arrest. A 70-yr-old woman with a history of hypertension, hyperlipidemia, coronary artery disease, and previous strokes presented with recurrent transient ischemic attacks of the left upper and lower extremities over the last 6 mo. She underwent right cervical endarterectomy (CEA) 16 yr prior. Neurological examination was unremarkable. Carotid Doppler ultrasonography revealed severely increased velocities of the right ICA. Cervical magnetic resonance angiography demonstrated 80% right ICA stenosis and 50% BTO stenosis. Digital subtraction cerebral angiography showed 80% right ICA stenosis and 70% BTO stenosis. The patient was not a candidate for standard carotid artery stenting because the BTO precluded endovascular access or for CEA because of the previous CEA; therefore, direct carotid access and flow reversal was an alternative. Under general anesthesia and systemic heparinization, the patient underwent right carotid artery surgical exposure. Under flow reversal using the Enroute System (Silk Road Medical, Sunnyvale, California), anterograde right ICA stenting angioplasty and retrograde BTO stenting and angioplasty were performed. Successful revascularization of the right ICA and BTO was obtained. No procedure-related complications occurred. The patient was discharged home 2 d postprocedure, neurologically intact. Direct carotid access with flow reversal is a safe and effective therapeutic alternative for patients with ICA (or common carotid artery) stenosis who cannot undergo CEA or when endovascular access from the aortic arch is not possible. Patient consent was obtained prior to performing the procedure. Institutional board approval is not required for the report of a single case.

Abstract We present a case of a traumatic skull base internal carotid artery (ICA) pseudoaneurysm treated with endovascular flow diversion stenting. The patient was a 27-year-old male who was involved in a motorcycle accident suffering multiple traumatic injuries including a large skull base fracture that extended through the carotid canal. Computed tomography angiography revealed a 2-cm right ICA pseudoaneurysm. Once the patient was stable, a digital subtraction angiography demonstrated enlargement of the pseudoaneurysm. After his other injuries were addressed by trauma and orthopedic surgery, at day 9 after his initial injury, the patient was loaded with aspirin and clopidrogel in preparation for stent reconstruction of his ICA injury. Under conscious sedation and systemic heparinization, the patient underwent endovascular reconstruction of the large pseudoaneurysm using telescoping flow diversion stents. Immediate intra-aneurysm flow stasis was observed. No procedure-related complications occurred. The patient did well and at last follow-up remained neurologically intact.

Abstract BACKGROUND Neck remnants are not uncommon after endovascular treatment of cerebral aneurysms. Critics of endovascular treatments for cerebral aneurysms cite neck remnants as evidence in favor of microsurgical clipping. However, studies have failed to evaluate the true clinical significance of aneurysm neck remnants following endovascular therapies. OBJECTIVE To assess the clinical significance of residual aneurysm necks and to determine the rate of subsequent rupture following coiling or stent-assisted coiling of cerebral aneurysms. METHODS We retrospectively reviewed the records of 1292 aneurysm cases that underwent endovascular treatment at 4 institutions. Aneurysms treated by primary coiling or stent-assisted coiling were included in the study; those treated by flow diversion were excluded Aneurysms with residual filling (i.e., Raymond–Roy Occlusion Classification II, neck remnant; or III, residual aneurysm filling) were assessed for their risk of subsequent rupture. RESULTS A total of 626 aneurysms were identified as having residual filling immediately posttreatment. Of these, 13 aneurysms (2.1%) ruptured during the follow-up period (mean 7.3 mo; range 1-84 mo). Eleven of the 13 (84.6%) were ruptured at presentation. Rupture at presentation, the size of the aneurysm, and the increasing age of the patient were predictive of posttreatment rupture. CONCLUSION We found that unruptured aneurysms with residual necks following endovascular treatment posed a very low risk of rupture (0.6%). However, patients presenting with ruptured aneurysms had a higher risk of rerupture from a neck remnant (3.4%). These results highlight the importance of achieving complete angiographic occlusion of ruptured aneurysms.

Abstract The University at Buffalo's neuroendovascular fellowship is one of the longest running fellowship programs in North America. The burgeoning neurointerventional workforce and the rapid growth in the neurointerventional space on the heels of groundbreaking clinical trials prompted us to assess the fellowship's academic impact and its graduates’ perceptions and productivity. An anonymized web-based survey was sent to all former neuroendovascular fellows with specific questions pertaining to current practice, research and funding, and perceptions about the fellowship's impact on their skills, competitiveness, and compensation. Additionally, the h -index was calculated to assess the academic productivity of each graduated fellow. Among 50 former fellows, 42 (84%) completed the survey. The fellows came from various countries, ethnic backgrounds, and specialties including neurosurgery (n = 39, 93%), neurology (n = 2, 5%), and neuroradiology (n = 1, 2%). Twenty (48%) respondents were currently chairs or directors of their practice. Most (n = 30, 71%) spent at least 10% of their time on research activities, with 27 (64%) receiving research funding. The median h -index of all 50 former fellows was 14. The biggest gains from the fellowship were reported to be improvement in endovascular skills (median = 10 on a scale of 0-10 [highest]) and increase in competitiveness for jobs in vascular neurosurgery (median = 10), followed by increase in academic productivity (median = 8), and knowledge of vascular disease (median = 8). In an era with open calls for moratoriums on endovascular fellowships, concerns over market saturation, and pleas to improve training, fellowship programs perhaps merit a more objective assessment. The effectiveness of a fellowship program may best be measured by the academic impact and leadership roles of former fellows.

Abstract BACKGROUND Neuroendovascular intervention has become a key treatment option for acute ischemic stroke. The Sofia (6F) PLUS catheter was designed for neurovascular access for diagnostic or therapeutic interventions. OBJECTIVE To report the first series describing use of the Sofia PLUS intermediate/distal access reperfusion catheter in the treatment of acute ischemic stroke. METHODS In this retrospective study, 41 stroke cases were identified in which the catheter was utilized for thrombolysis/thrombectomy. Mean preprocedure National Institutes of Health Stroke Scale score was 16.5 ± 5.2 (range 4-29). Occluded vessels included the M1 segment, M2 segment, internal carotid artery terminus, cervical internal carotid artery, and basilar artery. RESULTS Successful positioning of the Sofia PLUS catheter near the occlusion site was achieved in 38 (92.7%) of 41 cases in which thrombectomy or thrombolysis was attempted using intraarterial tissue plasminogen activator, a direct aspiration first-pass technique, and/or stent retrieval. A postprocedure thrombolysis in cerebral infarction (TICI) score of 2b/3 was achieved in 37 of 41 cases. Of 15 cases where the Sofia PLUS was used for a direct aspiration first-pass technique, TICI 2b/3 was achieved in 11 (73.3%). In one case where intra-arterial tissue plasminogen activator was used as the only treatment modality, TICI 2a was achieved. No device-related or catheter-related complications were observed. The mean 7-d-postprocedure National Institutes of Health Stroke Scale score among the 39 survivors was 8.5 ± 7.3 (range 0-23). CONCLUSION Initial results with use of the Sofia (6F) PLUS for endovascular treatment of acute ischemic stroke have been encouraging. Experience with a larger series is warranted to further evaluate the safety and efficacy of this device and compare it with other reperfusion catheters.