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endovascular_treatment

Endovascular treatment

Endovascular interventions have become an essential part of a neurosurgeon's practice.

The need for emergent neurosurgical procedures is very low among patients undergoing intracranial neuroendovascular procedures. Survival in such patients despite emergent neurosurgical procedures is quite low 1).

A study suggest potential gaps in the training of neurosurgery residents with regard to endovascular neurosurgery. In an era of minimally invasive therapies, changes in residency curricula may be needed to keep pace with the ever-changing field of neurosurgery 2)

The femoral artery is usually punctured below the inguinal ligament for neuroendovascular procedures with a 18-19 gauge needle.

To place the wire with Seldinger technique in the artery with removal of the percutaneous needle and the introduction of the sheath 3).

The sheath is removed at the end of the procedure, then manual compression should be performed for 10-20 minutes to achieve hemostasis.

This minimizes the risk of local and embolic complications.

Remove the sheath only when the Activated Partial Thromboplastin Time (aPTT) has returned to normal (< 36 secs) or when the Activated Clotting Time (ACT) is < 170.

see femoral arterial closure device.

Endovascular treatment by mechanical thrombectomy will be increasingly chosen as an adjunctive or alternative to intravenous thrombolysis. To apply this form of stroke treatment is associated with the challenge of optimal periinterventional treatment. The patient has to be identified, counselled, prepared, monitored, cardiovascularly stabilized, possibly sedated and ventilated, and postprocedurally treated in the optimal way. However, most aspects of periinterventional treatment have as yet not been clarified and require prospective research. Among these, the question of general anesthesia vs conscious sedation has received most attention and may be the most crucial one. Based on a great amount of retrospective data, it appears reasonable to start the intervention under conscious sedation of the non-intubated patient with standby measures for emergent intubation, until prospective randomized trials have clarified that issue. Periinterventional management will significantly affect the success of recanalization 4).

The expansion of endovascular techniques for intracranial aneurysms has led to a global decrease in vascular neurosurgery activity. This situation might impact neurosurgeons' level of expertise, even though they all might have to deal with this surgically challenging pathology, and pleads for the use of training and simulation programmes dedicated to neurovascular surgery 5).

Indications

Intracranial aneurysm

Stroke

Endovascular management of acute ischemic stroke (AIS) in the setting of carotid artery dissection (CAD) is a feasible, safe, and promising strategy 6).

Endovascular therapy was associated with better outcomes and higher cost-recovery than IV thrombolysis in patients with large vessel strokes 7).

Arteriovenous malformation

Arteriovenous fistula

Acute embolic stroke

Cerebrovascular arterial dissections

Internal carotid stenosis

Tumors

Intracranial atherosclerosis

Inferior petrosal sinus sampling

Technique

A stable intracranial guide catheter position within the intracranial vasculature is critical for safe, successful endovascular treatment

Pharmacological Agents

Eptifibatide

Abciximab

Tirofiban

Neuroendovascular treatment in Japan is increasing and the outcomes of such therapy are clinically acceptable. Details of each type of treatment will be investigated in sub-analyses of the database 8).

The risk of hemorrhage must be considered when using anticoagulation and antiplatelet therapy in patients requiring ventriculostomy. Interventionalists must not only work closely with neurosurgeons when it is anticipated that a ventriculostomy may be needed but also ensure that there is good communication with the neurosurgical team during the postprocedural period 9).

Complications

Analysis of retrospectively collected data from procedure logs and patient charts was performed to identify patients who required immediate (before the termination of the intervention) or adjunctive (within 24 hours of the intervention) neurosurgical procedures related to a neuroendovascular intervention complication. The types of neurosurgical procedures and in-hospital outcomes of identified patients are reported as an aggregate and per endovascular procedure-type analyses.

Khatri et al, reviewed a total of 933 neuroendovascular procedures performed during 3.5 years (2006-2010). A total of 759 intracranial procedures were performed. There was a need for emergent neurosurgical procedures in 8 patients (0.85% cumulative incidence and 1.05% for major intracranial procedures) (mean age, 46 years; 7 were women); the procedures were categorized as 3 immediate and 5 adjunctive procedures. There were 5 in-hospital deaths (62.5%) among these 8 patients. Neurosurgical procedures performed were external ventricular drainage placement in 6 (6 of 8, 75%) patients, decompressive craniectomy in 1 (12.5%) patient, and both surgical procedures in 1 (12.5%) patient.

The need for emergent neurosurgical procedures is very low among patients undergoing intracranial neuroendovascular procedures. Survival in such patients despite emergent neurosurgical procedures is quite low 10).


Complications

Although extremely rare, retention of foreign bodies such as microcatheters or micro guidewires can occur during various endovascular treatment due to gluing of the microcatheter tip or entanglement of the micro guidewire tip with intravascular devices.

Koo et al., have experienced 2 cases of irresolvable wire retention, one after flow diverter placement for a left cavernous internal carotid artery aneurysm and the other after intracranial stenting for acute basilar artery occlusion. The first patient presented 6 weeks after her procedure with right lung parenchymal hemorrhage due to direct piercing of the lung parenchyma after the retained wire fractured and migrated out of the aortic arch. The second patient presented 4 years after his procedure with pneumothorax due to migration of the fractured guidewire segment into the right thoracic cavity. In this report, the authors discuss the possible mechanisms of these unusual complications and how to prevent delayed consequences from a retained intravascular metallic wire 11).

1)
Khatri R, Ansar M, Sultan F, Chaudhry SA, Khan AA, Rodriguez GJ, Tummala RP, Qureshi AI. Requirements for emergent neurosurgical procedures among patients undergoing neuroendovascular procedures in contemporary practice. AJNR Am J Neuroradiol. 2012 Mar;33(3):465-8. doi: 10.3174/ajnr.A2787. Epub 2011 Nov 24. PubMed PMID: 22116112.
2)
Chalouhi N, Zanaty M, Tjoumakaris S, Manasseh P, Hasan D, Bulsara KR, Starke RM, Lawson K, Rosenwasser R, Jabbour P. Preparedness of neurosurgery graduates for neuroendovascular fellowship: a national survey of fellowship programs. J Neurosurg. 2015 Apr 3:1-7. [Epub ahead of print] PubMed PMID: 25839924.
3)
Osborn AG, Diagnostic Cerebral Angiography.Lippincott Williams & Wilkins, Philadelphia, PA: 1999.
4)
Bösel J. Management of the Interventional Stroke Patient. Curr Treat Options Neurol. 2015 Oct;17(10):45. doi: 10.1007/s11940-015-0376-z. PubMed PMID: 26387814.
5)
Le Reste PJ, Henaux PL, Riffaud L, Haegelen C, Morandi X. Influence of cumulative surgical experience on the outcome of poor-grade patients with ruptured intracranial aneurysm. Acta Neurochir (Wien). 2015 Jan;157(1):1-7. doi: 10.1007/s00701-014-2241-3. Epub 2014 Sep 25. PubMed PMID: 25248329.
6)
Haussen DC, Jadhav A, Jovin T, Grossberg J, Grigoryan M, Nahab F, Obideen M, Lima A, Aghaebrahim A, Gulati D, Nogueira RG. Endovascular Management vs Intravenous Thrombolysis for Acute Stroke Secondary to Carotid Artery Dissection: Local Experience and Systematic Review. Neurosurgery. 2015 Oct 21. [Epub ahead of print] PubMed PMID: 26492430.
7)
Rai AT, Evans K. Hospital-based financial analysis of endovascular therapy and intravenous thrombolysis for large vessel acute ischemic strokes: the 'bottom line'. J Neurointerv Surg. 2014 Jan 29. doi: 10.1136/neurintsurg-2013-011085. [Epub ahead of print] PubMed PMID: 24476964.
8)
Sakai N, Yoshimura S, Taki W, Hyodo A, Miyachi S, Nagai Y, Sakai C, Satow T, Terada T, Ezura M, Hyogo T, Matsubara S, Hayashi K, Fujinaka T, Ito Y, Kobayashi S, Komiyama M, Kuwayama N, Matsumaru Y, Matsumoto Y, Murayama Y, Nakahara I, Nemoto S, Satoh K, Sugiu K, Ishii A, Imamura H. Recent Trends in Neuroendovascular Therapy in Japan: Analysis of a Nationwide Survey-Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2. Neurol Med Chir (Tokyo). 2013 Dec 27. [Epub ahead of print] PubMed PMID: 24390188.
9)
Ross IB, Dhillon GS. Ventriculostomy-related cerebral hemorrhages after endovascular aneurysm treatment. AJNR Am J Neuroradiol. 2003 Sep;24(8):1528-31. PubMed PMID: 13679264.
10)
Khatri R, Ansar M, Sultan F, Chaudhry SA, Khan AA, Rodriguez GJ, Tummala RP, Qureshi AI. Requirements for emergent neurosurgical procedures among patients undergoing neuroendovascular procedures in contemporary practice. AJNR Am J Neuroradiol. 2012 Mar;33(3):465-8. doi: 10.3174/ajnr.A2787. PubMed PMID: 22116112.
11)
Koo HW, Park W, Yang K, Park JC, Ahn JS, Kwon SU, Hwang C, Lee DH. Fracture and migration of a retained wire into the thoracic cavity after endovascular neurointervention: report of 2 cases. J Neurosurg. 2017 Feb;126(2):354-359. doi: 10.3171/2015.12.JNS152381. PubMed PMID: 26991391.
endovascular_treatment.txt · Last modified: 2017/02/04 10:56 (external edit)