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Operative Neurosurgery (Hagerstown, Md.) Jun 2024Fetal posterior communicating artery (PComA) is a variant of the cerebral vasculature.1 Woven endobridge (WEB) embolization carries a good safety profile as treatment...
Lateral Supraorbital Approach for Microsurgical Clipping of Recurrent Ruptured Fetal Posterior Communicating Artery Aneurysm Initially Treated With Woven Endobridge Embolization and Flow Diversion: 2-Dimensional Operative Video.
Fetal posterior communicating artery (PComA) is a variant of the cerebral vasculature.1 Woven endobridge (WEB) embolization carries a good safety profile as treatment for ruptured wide neck PComA aneurysms, without the need for antiplatelet therapy. However, the reported occlusion rates are not optimal.2 Flow diversion is suboptimal in treating aneurysms originating from fetal PComA.3 Here we present a case of a 78-year-old female patient with a history of ruptured right fetal PComA aneurysm with wide base. It was initially treated with WEB embolization at an outside hospital. After WEB implantation, the initial follow-up of cerebral angiogram (6 months later) demonstrated a neck recurrence measuring 6 × 3 mm. Approximately 1 year after the initial treatment, pipeline embolization was performed and patient was placed on antiplatelet therapy since. Follow-up images demonstrated a 6 mm × 4 mm persistent neck remnant. Her care was transferred to our institution. Cerebral angiogram obtained 36 months post-WEB implantation showed growth of the neck remnant measuring 9 × 8.5 mm. The WEB device was found to be folded in the aneurysmal fundus. Given this was a growing recurrent previously ruptured fetal PComA aneurysm with a pipeline stent in the internal carotid artery the decision was made to retreat with microsurgical clipping; carotid access at the neck was required for proximal control. We achieved complete aneurysm obliteration through a minimal invasive approach. The patient gave informed consent for surgery and video recording. Institutional Review Board approval was deemed unnecessary.
PubMed: 38847515
DOI: 10.1227/ons.0000000000001222 -
The International Journal of Angiology... Jun 2024Pulmonary embolism (PE) is a common disease associated with significant morbidity and mortality. Despite the familiarity with this disease, the best treatment remains... (Review)
Review
Pulmonary embolism (PE) is a common disease associated with significant morbidity and mortality. Despite the familiarity with this disease, the best treatment remains undefined. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis, or surgery. However, the debate over pharmacologic versus mechanical treatment of acute PE reared up again with the advent of user-friendly mechanical and aspiration thrombectomy technologies. This is especially true for submassive PE, which is an area for potential growth both for understanding the pathophysiology of the disease process and management. Multiple devices are available for treatment of PE. Understanding the risks and benefits of each device is paramount in the complex management of PE.
PubMed: 38846990
DOI: 10.1055/s-0044-1782535 -
The International Journal of Angiology... Jun 2024Inferior vena cava (IVC) filters and endovascular devices are used to mitigate the risk of pulmonary embolism in patients presenting with lower extremity venous... (Review)
Review
Inferior vena cava (IVC) filters and endovascular devices are used to mitigate the risk of pulmonary embolism in patients presenting with lower extremity venous thromboembolism in whom long-term anticoagulation is not a good option. However, the efficacy and benefit of these devices remain uncertain, and controversies exist. This review focuses on the current use of IVC filters and other endovascular therapies in clinical practice. The indications, risks, and benefits are discussed based on current data. Further research and randomized controlled trials are needed to characterize the patient population that would benefit most from these interventional therapies.
PubMed: 38846989
DOI: 10.1055/s-0044-1785231 -
Stroke (Hoboken, N.J.) Mar 2024Currently, endovascular treatment of intracranial aneurysms (ICAs) is limited by low complete occlusion rates. The advent of novel endovascular technology has expanded...
BACKGROUND
Currently, endovascular treatment of intracranial aneurysms (ICAs) is limited by low complete occlusion rates. The advent of novel endovascular technology has expanded the applicability of endovascular therapy; however, the superiority of novel embolic devices over the traditional Guglielmi detachable coils (GDCs) is still debated. We performed a systematic review of literature that reported Raymond-Roy occlusion classification (RROC) rates of modern endovascular devices to determine their immediate and follow-up occlusion effectiveness for the treatment of unruptured saccular ICAs.
METHODS
A search was conducted using electronic databases (PUBMED, Cochrane, ClinicalTrials.gov, Web of Science). We retrieved studies published between 2000-2022 reporting immediate and follow-up RROC rates of subjects treated with different endovascular ICA therapies. We extracted demographic information of the treated patients and their reported angiographic RROC rates.
RESULTS
A total of 80 studies from 15 countries were included for data extraction. RROC rates determined from angiogram were obtained for 21,331 patients (72.5% females, pooled mean age: 58.2 (95% CI: 56.8-59.6), harboring 22,791 aneurysms. The most frequent aneurysm locations were the internal carotid artery (46.4%, 95% CI: 41.9%-50.9%), the anterior communicating artery (26.4%, 95% CI: 22.5%-30.8%), the middle cerebral artery (24.5%, 95% CI:19.2%-30.8%) and the basilar tip (14.4%, 95% CI:11.3%-18.3%). The complete occlusion probability (RROC-I) was analyzed for GDCs, the Woven EndoBridge (WEB), and flow diverters. The RROC-I rate was the highest in balloon-assisted coiling (73.9%, 95% CI: 65.0%-81.2%) and the lowest in the WEB (27.8%, 95% CI:13.2%-49.2%). The follow-up RROC-I probability was homogenous in all analyzed devices.
CONCLUSIONS
We observed that the coil-based endovascular therapy provides acceptable rates of complete occlusion, and these rates are improved in balloon-assisted coils. Out of the analyzed devices, the WEB exhibited the shortest time to achieve >90% probability of follow-up complete occlusion (~18 months). Overall, the GDCs remain the for endovascular treatment of unruptured saccular aneurysms.
PubMed: 38846323
DOI: 10.1161/SVIN.123.001118 -
Clinical Orthopaedics and Related... Jun 2024Magnetic intramedullary lengthening nailing has demonstrated benefits over external fixation devices for femoral bone lengthening. These include avoiding uncomfortable...
BACKGROUND
Magnetic intramedullary lengthening nailing has demonstrated benefits over external fixation devices for femoral bone lengthening. These include avoiding uncomfortable external fixation and associated pin site infections, scarring, and inhibition of muscle or joint function. Despite this, little has changed in the field of biologically enhanced bone regeneration. Venting the femoral intramedullary canal at the osteotomy site before reaming creates egress for bone marrow during reaming. The reamings that are extruded from vent holes may function as a prepositioned bone graft at the distraction gap. The relationship between venting and the consolidation of regenerating bone remains unclear.
QUESTIONS/PURPOSES
(1) Do bone marrow reamings extruded through venting holes enhance the quality of bone regeneration and improve healing indices and consolidation times? (2) Is venting associated with a higher proportion of complications than nonventing?
METHODS
We performed a retrospective study of femoral lengthening performed at one hospital from December 2012 to February 2022 using a magnetic intramedullary lengthening nail with or without venting at the osteotomy site before reaming. This was a generally sequential series, in which the study groups were assembled as follows: Venting was performed between July 2012 and August 2016 and again from November 2021 onward. Nonventing was used between October 2016 and October 2021 because the senior author opted to create drill holes after the reaming procedure to avoid commitment to the osteotomy level before completing the reaming procedure. Outcomes were evaluated based on bone healing time, time to achieve full weightbearing, and complications. Sixty-one femoral lengthening procedures were studied (in 33 male and 28 female patients); two patients were excluded because of implant breakage. The mean age was 17 ± 5 years. The mean amount of lengthening was 55 ± 13 mm in the venting group and 48 ± 16 mm in the nonventing group (mean difference 7 ± 21 [95% CI 2 to 12]; p = 0.07). The healing index was defined as the time (in days) required for three cortices to bridge with new bone formation divided by the length (in cm) lengthened during the clinical protocol. This index signifies the bone formation rate achieved under the specific conditions of the protocol. Full weightbearing was allowed upon bridging the regenerated gap on three sides. Consolidation time was defined as the total number of days from the completion of the lengthening phase until adequate bone union (all three cortices healed) was achieved and full weightbearing was permitted. This time frame represents the entire healing process after the lengthening is complete divided by the amount of lengthening achieved (in cm). Patient follow-up was conducted meticulously at our institution, and we adhered to a precise schedule, occurring every 2 weeks during the distraction phase and every 4 weeks during the consolidation phase. There were no instances of loss to follow-up. Every patient completed the treatment successfully, reaching the specified milestones of weightbearing and achieving three cortexes of bone bridging.
RESULTS
The mean healing index time in the venting group was faster than that in the nonventing group (21 ± 6 days/cm versus 31 ± 22 days/cm, mean difference 10 ± 23 [95% CI 4 to 16]; p = 0.02). The mean consolidation time was faster in the venting group than the nonventing group (10 ± 6 days/cm versus 20 ± 22 days/cm; mean difference 10 ± 23 [95% CI 4 to 15]; p = 0.02). No medical complications such as deep vein thrombosis or fat or pulmonary embolism were seen. Two patients had lengthy delays in regenerate union, both of whom were in the nonventing group (healing indexes were 74 and 62 days/cm; consolidation time was 52 and 40 days/cm).
CONCLUSION
Femoral lengthening with a magnetic intramedullary lengthening nail healed more quickly with prereaming venting than with nonventing, and it allowed earlier full weightbearing without any major associated complications. Future studies should evaluate whether there is a correlation between the number of venting holes and improvement in the healing index and consolidation time.
LEVEL OF EVIDENCE
Level III, therapeutic study.
PubMed: 38843493
DOI: 10.1097/CORR.0000000000003119 -
Catheterization and Cardiovascular... Jun 2024The clinical efficacy and safety of a novel left atrial appendage (LAA) occluder of the SeaLA closure system in patients with nonvalvular atrial fibrillation (NVAF) were...
OBJECTIVES
The clinical efficacy and safety of a novel left atrial appendage (LAA) occluder of the SeaLA closure system in patients with nonvalvular atrial fibrillation (NVAF) were reported.
BACKGROUND
Patients with NVAF are at a higher risk of stroke compared to healthy individuals. Left atrial appendage closure (LAAC) has emerged as a prominent strategy for reducing the risk of thrombosis in individuals with NVAF.
METHODS
A prospective, multicenter study was conducted in NVAF patients with a high risk of stroke.
RESULTS
The LAAC was successfully performed in 163 patients. The mean age was 66.93 ± 7.92 years, with a mean preoperative CHA2DS2-VASc score of 4.17 ± 1.48. One patient with residual flow >3 mm was observed at the 6-month follow-up, confirmed by TEE. During the follow-up, 2 severe pericardiac effusions were noted, and 2 ischemic strokes were observed. Four device-related thromboses were resolved after anticoagulation treatment. There was no device embolism.
CONCLUSIONS
The LAAC with the SeaLA device demonstrates encouraging feasibility, safety, and efficacy outcomes.
PubMed: 38841867
DOI: 10.1002/ccd.31056 -
Interventional Cardiology Clinics Jul 2024Pulmonary artery stent implantation has become integral in the treatment of pulmonary artery stenosis and is probably the most efficacious therapy for these lesions.... (Review)
Review
Pulmonary artery stent implantation has become integral in the treatment of pulmonary artery stenosis and is probably the most efficacious therapy for these lesions. Advancements in technology involving stent design and the equipment used for stent delivery have made this procedure much safer and more effective. Strategies to mitigate and successfully treat adverse events related to pulmonary artery stent implantation are reasonably well-established. Pulmonary artery stent implantation remains one of the most complex and technically challenging of congenital cardiac interventions.
Topics: Humans; Stents; Pulmonary Artery; Stenosis, Pulmonary Artery; Prosthesis Design
PubMed: 38839173
DOI: 10.1016/j.iccl.2024.03.008 -
Catheterization and Cardiovascular... Jun 2024Randomized clinical trials failed to show additional benefit of renal artery stenting on top of medical therapy. Instead of writing an obituary on renal artery stenting,... (Review)
Review
Randomized clinical trials failed to show additional benefit of renal artery stenting on top of medical therapy. Instead of writing an obituary on renal artery stenting, we try to explain these disappointing results. A transstenotic pressure gradient is needed to reduce renal perfusion and to activate the renin-angiotensin-aldosterone system. In only a minority of patients included in trials, a transstenotic pressure gradient is measured and reported. Like the coronary circulation, integration of physiological lesion assessment will allow to avoid stenting of non-significant lesions and select those patients that are most likely to benefit from renal artery stenting. Renal artery interventions are associated with peri-procedural complications. Contemporary techniques, including radial artery access, no-touch technique to engage the renal ostium and the use of embolic protection devices, will minimize procedural risk. Combining optimal patient selection and meticulous technique might lead to a netto clinical benefit when renal artery stenting is added to optimal medical therapy.
PubMed: 38837309
DOI: 10.1002/ccd.31117 -
Circulation. Cardiovascular... Jun 2024Cerebral embolic protection devices (EPDs) were developed to mitigate the risk of stroke during transcatheter aortic valve replacement (TAVR), but their benefit remains...
Cerebral embolic protection devices (EPDs) were developed to mitigate the risk of stroke during transcatheter aortic valve replacement (TAVR), but their benefit remains unproven. In the PROTECTED-TAVR trial, EPD use did not reduce periprocedural stroke (primary study outcome) but led to a 62% reduction in the secondary endpoint of disabling stroke. Given these results, the impact of EPDs during TAVR remains unclear. We used STS/ACC TVT registry data to examine the association between EPD use and a proxy for disabling stroke among transfemoral TAVR patients between 1/2018-6/2023. The primary outcome was in-hospital disabling stroke-defined as stroke associated with either in-hospital death or discharge to a non-home location. We evaluated the association between EPD use and disabling stroke using instrumental variable (IV) analysis with site-level preference for EPD use as the instrument-a quasi-experimental approach that can support causal inference. In addition, we performed a propensity-score based comparison using overlap weighting as a secondary analysis. The study population consisted of 414,649 patients of whom 53,389 (12.9%) received an EPD. The unadjusted rate of in-hospital disabling stroke was 0.7% among the EPD group and 0.9% in the no EPD group. EPD use was associated with a reduction in disabling stroke in both IV analysis (RR 0.87; 95% CI: 0.73-1.00) and propensity-weighted (PW) analysis (OR 0.79; 95% CI: 0.70-0.90) but was not associated with a reduction in non-disabling stroke. In subgroup analyses, the benefit of EPD was greater among those with versus without prior stroke (interaction p<0.05 for IV and PW). In the largest study to date, among patients undergoing TAVR, EPD use was associated with a small, borderline significant reduction in stroke associated with death or a discharge to a non-home location (a proxy for disabling stroke) that is likely to be causal in nature. Taken together with previous mechanistic and clinical studies, these findings provide credible evidence that EPDs benefit patients undergoing TAVR.
PubMed: 38837174
DOI: 10.1161/CIRCINTERVENTIONS.123.013697 -
Frontiers in Cardiovascular Medicine 2024Patent Foramen Ovale (PFO) is a common congenital atrial septal defect present in 20%-35% of the general population. Although generally considered a benign anatomic... (Review)
Review
Patent Foramen Ovale (PFO) is a common congenital atrial septal defect present in 20%-35% of the general population. Although generally considered a benign anatomic variant, a PFO may facilitate passage of a thrombus from the venous to arterial circulation, thereby resulting in cryptogenic stroke or systemic embolization. A PFO is detected in nearly one half of patients presenting with cryptogenic stroke and often considered the most likely etiology when other causes have been excluded. In this review, we discuss the contemporary role of transcatheter closure of PFO in the treatment of cryptogenic stroke, including devices currently available for commercial use in the United States (Amplatzer PFO Occluder and Gore Cardioform Septal Occluder) and a novel suture-mediated device (NobleStitch EL) under clinical investigation. To provide the best care for cryptogenic stroke patients, practitioners should be familiar with the indications for PFO closure and corresponding treatment options.
PubMed: 38832314
DOI: 10.3389/fcvm.2024.1391886