The Safety and Effectiveness of the Prostar XL Closure Device Compared to Open Groin Cutdown for Endovascular Aneurysm Repair

OBJECTIVE

The aim of this study is to compare the outcomes of percutaneous femoral closure with the Prostar XL for endovascular aneurysm repair (EVAR) to those of open femoral cutdown, and to evaluate factors which may predict the failure of percutaneous closure.

METHODS

Patients undergoing endovascular aneurysm repair for an infrarenal abdominal aortic aneurysm between 2005 and 2013 were included. Patient characteristics, anatomic femoral artery measurements, and postoperative complications were recorded retrospectively. Operator experience was defined with a cut-off point of >30 Prostar XL closures performed. Comparisons were made per access site.

RESULTS

A total of 443 access sites were included, with percutaneous closure used in 257 cases (58.0%) and open cutdown in 186 cases (42.0%). The complication rate was 2.7% for the percutaneous and 4.3% for the open cutdown group (P = .482). No significant differences between groups were found with respect to 30-day mortality, wound infections, thrombosis, seromas, or bleeding complications. Fourteen failures (5.4%) of percutaneous closure occurred. The success rates were similar for experienced and unexperienced operators (94.2% vs 95.5%, P = .768). Renal insufficiency was more common in the failed than in the successful percutaneous closure group (64.3% vs 24.7%, P = .003). Common femoral artery calcification or diameter, BMI, sheath size, or operator experience did not predict failure. No further complications were seen in follow-up CT at 1-3 years postoperatively.

CONCLUSION

The use of the Prostar XL is safe compared to open cutdown. The success rate is 94.6%. Operator experience, sheath size, obesity, or femoral artery diameter or calcification do not appear to predict a failure of percutaneous closure. Complications seem to occur perioperatively, and late complications are rare.

To patch, or not to patch a common femoral artery, that is the question

OBJECTIVES

There is no strong evidence to support or reject the use of patch angioplasty (PA) after femoral endarterectomy (FE). The current study aimed to assess early postoperative complications and compare primary patency (PP) rates after FE in patients treated with PA versus direct closure (DC).

METHODS

This is a retrospective study of patients admitted during 06/2002-07/2017 with signs and symptoms of chronic lower limb ischemia (Rutherford categories 2-6). Patients with angiographically confirmed stenoses or occlusions of the common femoral arteries (CFAs) and managed with FE with or without PA were included in the study. Early postoperative wound complications were assessed. The PP analysis was based on imaging-confirmed data. The impact of PA on the patency was evaluated in a confounder-adjusted Cox regression model. PP rates were compared with log-rank between the PA and DC groups using Kaplan-Meier survival analysis in the propensity score-matched (PSM) cohorts.

RESULTS

A total of 295 primary FEs were identified. The patients' median age was 75 years. A total of 210 patients were managed with PA and 85 with DC. Altogether, 38 (12.9%) local wound complications were registered, 15 (5.1%) of which required re-interventions. There were 9 (3.2%) cases of deep wound infection, 20 (7.0%) seromas, and 11 (3.9%) cases of major bleeding, with no significant difference between the PA and DC groups. All of the infected patches were made of synthetic material, and 83% of them were removed. The PP analysis was performed on 50 PSM patient pairs with a median age of 74 years. The median imaging-confirmed follow-up lengths were 77 months (IQR = 47 months) for the PA patients and 27 months (IQR = 64 months) for the DC patients. The preoperative median diameter of the CFA was 8.8 mm (IQR = 3.4). The 5 year primary patency rates of CFAs with a minimum diameter of 5.5 mm managed with PA or DC exceeded 91%, p > 0.05. Female sex was associated with the loss of PP, odds ratio 4.17, p = 0.046.

CONCLUSIONS

Wound complications after FE with or without patching are not uncommon and often lead to reoperations. The PP rates of CFAs with a minimum diameter of 5.5 mm and accomplished with or without patching are comparable. Female sex is associated with the loss of patency.

Multivariable Analysis of Pre-operative Brain Atrophy as a Predictor of Long Term Mortality After Carotid Endarterectomy

OBJECTIVE

Brain atrophy is associated with an increased mortality rate in elderly trauma patients and in patients treated with mechanical thrombectomy for acute ischaemic stroke. In the setting of ischaemic stroke, the association between brain atrophy and death is stronger than that of sarcopenia. It has previously been shown that lower masseter area, as a marker of sarcopenia, is linked to lower survival after carotid endarterectomy (CEA). The aim of this study was to investigate whether brain atrophy is also associated with long term mortality in patients undergoing CEA.

METHODS

A cohort of patients treated with CEA between 2004 and 2010 was retrieved from the Tampere University Hospital vascular registry and those with available pre-operative computed tomography (CT) imaging were analysed retrospectively. CT images were evaluated for brain atrophy index (BAI) and masseter muscle surface area and density. The association between BAI and mortality was investigated with Cox regression.

RESULTS

Two hundred and thirty-three patients with a median (interquartile range [IQR]) age of 71 years (64.0, 77.0) were included. Most patients were operated on for symptomatic stenosis (n = 203; 87.1%). The median (IQR) duration of follow up was 115.0 months (66.0, 153.0), and 155 patients (66.5%) died during follow up. BAI was statistically significantly correlated with age (r = .489), average masseter density (r = -.202), and smoking (r = -.186; all p <.005). Increased BAI was statistically significantly associated with overall mortality (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.25 - 1.68, per one standard deviation [SD] increase) in the univariable analysis, and the association remained (HR 1.23, 95% CI 1.04 - 1.46, per one SD increase) in the multivariable models. Age, peripheral artery disease, and chronic obstructive pulmonary disease were also independently associated with mortality. The optimal cutoff value for BAI was 0.133.

CONCLUSION

Brain atrophy independently predicts the long term post-operative mortality rate after CEA in a cohort containing mainly symptomatic patients. Future studies are needed to validate the results in prospective settings and in asymptomatic patients.

Long-term outcomes of endovascular aneurysm repair according to instructions for use adherence status

OBJECTIVE

Endovascular aneurysm repair (EVAR) has become a standard treatment method for abdominal aortic aneurysms (AAA). Endovascular device manufacturers have defined specific anatomic criteria for aneurysm characteristics to be observed as instructions for use (IFU) with specific grafts. In clinical practice, the prevalence of performing EVAR outside the IFU is high. This study aims to determine the impact of IFU criteria non-adherence on outcomes.

METHODS

Patients undergoing EVAR for an infrarenal AAA between 2005 and 2013 were included. IFU non-adherence was defined as any violation of device-specific IFU criteria and was compared to IFU adherence. Primary outcomes were all-cause mortality, aneurysm-related mortality, AAA ruptures, graft-related adverse events (GRAEs), including limb-related adverse events, and type Ia endoleaks. Secondarily, the aim was to study whether the prevalence of EVAR performed outside the IFU has increased over time.

RESULTS

A total of 258 patients were included, 144 (55.8%) of whom were treated according to the IFU criteria and 114 (44.2%) outside the criteria. In the IFU non-adherence group, all-cause mortality (HR 1.39, 95% CI 1.02-1.89, p = .037) and aneurysm-related mortality (HR 5.1, 95% CI 1.4-18.6, p = .015) were higher, as were the incidences of AAA ruptures (HR 5.4, 95 % CI 1.1-26.6, p = .036) and GRAEs (HR 1.7, 95% CI 1.1-2.8, p = .025). No significant association was found between type Ia endoleak and neck-related IFU or limb-related adverse events and iliac-related IFU. However, neck length was a risk factor for a type Ia endoleak (HR 18.2, 95% CI 6.3-52.2, p < .001), aneurysm-related mortality (HR=8.7, 95% CI 1.8-41.6, p = .007), rupture (HR= 21.7, 95% CI 2.8-166, p = .003), and GRAEs (HR 4.4, 95% CI 2.0-9.7, p < .001). An IFU violation regarding the neck angulation was also a risk factor for all-cause mortality (HR 2.0, 95% CI 1.1-3.7, p = .032), aneurysm-related mortality (HR 7.6, 95% CI 1.4-42.8, p = .021), AAA rupture (HR 79.4, 95% CI 6.3-999, p = .001), and GRAEs (HR 4.3, 95% CI 1.9-9.5, p < .001). The prevalence of EVAR performed outside the IFU did not increase over time.

CONCLUSIONS

Performing EVAR outside the IFU has a negative effect on outcomes, including all-cause mortality, aneurysm-related mortality, ruptures, and graft-related adverse events. Neck angulation and neck length seem to be the most crucial aneurysm characteristics.

The effect of suprarenal graft fixation during EVAR on short- and long-term renal function

OBJECTIVE

The effect of suprarenal fixation (SR) compared to infrarenal fixation (IR) on renal function during endovascular aneurysm repair (EVAR) remains controversial. This study aims to compare the renal outcomes between fixation types in short- and long-term follow-up.

METHODS

Patients undergoing EVAR for infrarenal abdominal aortic aneurysm between 2005 and 2013 were included. Estimated glomerular filtration rate (eGFR) was measured at baseline and during a follow-up of 5 years. A decline in renal function was defined as a ≥ 20% decrease in eGFR. Changes in eGFR were compared between SR and IR groups at 1-7 days, 30 days, and 1-5 years postoperatively. Preoperative renal insufficiency was defined as eGFR < 60mL/min/1.73m², and those patients were included in the subanalyses.

RESULTS

A total of 358 patients were included. Among these, 267 (74.6%) had SR and 91 (25.4%) had IR fixation. A decline in renal function occurred more commonly after SR than after IR in 1-7 days postoperatively (p = .009), but no difference was noticed at 30 days and 1-5 years. Regardless of the fixation method, renal function steadily decreased steadily over time after EVAR (estimate -3.13 per a year, 95% confidence interval -3.40- -2.85, p < .001). Patients with pre-existing renal insufficiency were included in subgroup analyses, and those with SR were more often found to have a decline in eGFR 5 years postoperatively than their counterparts with IR (59.5% vs 20.0%, p = .036).

CONCLUSION

An immediate postoperative decline in renal function was seen more often after SR fixation than IR fixation but this difference was transient. SR fixation is a safe method for patients with normal renal function. Long-term results seems to favor IR over SR in patients with pre-existing renal insufficiency.

In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

Purpose

Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO.

Materials and Methods

We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis.

Results

Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients.

Conclusions

MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

Supplementary Information

The online version of this article (10.1007/s00270-020-02727-8) contains supplementary material, which is available to authorized users.

Anemia Predicts Poor Clinical Outcome in Mechanical Thrombectomy Patients with Fair or Good Collateral Circulation

Background and Purpose

Anemia predicts poor clinical outcome of ischemic stroke in the general stroke population. We studied whether this applies to those treated with mechanical thrombectomy for proximal anterior circulation occlusion in the setting of differing collateral circulation.

Methods

We collected the data of 347 consecutive anterior circulation stroke patients who underwent mechanical thrombectomy after multimodal CT imaging in a single tertiary stroke care center. Patients with occlusion of the internal carotid artery and/or the first segment of the middle cerebral artery were included. We recorded baseline clinical, laboratory, procedural, and imaging variables, and the technical, imaging, and clinical outcomes. Differences between anemic and nonanemic patients were studied with appropriate statistical tests and binary logistic regression analysis.

Results

Ninety-four out of the 285 patients eligible for analysis had anemia, and 243 had fair or good collateral circulation (collateral score, CS, >0). Fifty-four percent of the patients experienced good 3-month clinical outcome (modified Rankin Scale ≤2). In pooled analyses of the CS 1–4 and 2–4 ranges, nonanemic patients had good clinical outcome significantly more often (p < 0.001 for both). This effect was not seen in patients with poor collateral circulation (CS = 0). Nonanemic patients had significantly better odds of good clinical outcome (OR = 2.6, 95% CI 1.377–5.030, p = 0.004) in a binary regression model. A 0.1 g/dL increase in hemoglobin improved the odds of good clinical outcome by 2% (OR = 1.02, 95% CI 1.002–1.044, p = 0.03).

Conclusions

Low hemoglobin on admission predicts poor clinical outcome in mechanical thrombectomy patients with fair or good collateral circulation.

Brain atrophy predicts mortality after mechanical thrombectomy of proximal anterior circulation occlusion

BACKGROUND

Brain atrophy is associated with an inferior functional outcome in patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke. We hypothesized that brain atrophy determined from pre-interventional non-contrast-enhanced CT scans would also be linked to increased mortality in this cohort.

METHODS

A total of 204 patients treated with MT for acute occlusions of the internal carotid artery (ICA) or the M1 segment of the middle cerebral artery (M1) at Tampere University Hospital, Finland between 2013 and 2017 were retrospectively studied. Brain atrophy index (BAI), masseter muscle surface area and density, chronic ischemic lesions, and white matter lesions were evaluated from pre-interventional CT studies. Logistic regression was applied in analyzing the association of BAI with 3-month mortality.

RESULTS

Median age at baseline was 69.9 years (IQR 15.6) and mortality at 3 months was 13.2% (n=27). BAI, measured with excellent reproducibility (intraclass correlation coefficient ≥0.894, p<0.001), was significantly associated with age (r=0.54), white matter lesions (r=0.43), dental status (r=-0.31), masseter area (r=-0.24), masseter density (r=-0.28), and chronic ischemic lesions (r=0.24) (p≤0.001 for all). In univariable analysis, BAI demonstrated a strong association with mortality (OR 2.02, 95% CI 1.34 to 3.05, per 1 SD increase), and none of the other factors associated with mortality remained as significant when included in the same multivariable model. The results remained similar when extending the follow-up up to 2.5 years.

CONCLUSIONS

Brain atrophy predicts 3-month mortality after MT of the ICA or the M1 independent of age, masseter sarcopenia, chronic ischemic lesions, or white matter lesions.

Association of masseter area and radiodensity with three-month survival after proximal anterior circulation occlusion

BACKGROUND

Masseter area (MA), a surrogate for sarcopenia, appears to be useful when estimating postoperative survival, but there is lack of consensus regarding the potential predictive value of sarcopenia in acute ischemic stroke (AIS) patients. We hypothesized that MA and density (MD) evaluated from pre-interventional CT angiography scans predict postinterventional survival in patients undergoing mechanical thrombectomy (MT).

MATERIALS AND METHODS

312 patients treated with MT for acute occlusions of the internal carotid artery (ICA) or the M1 segment of the middle cerebral artery (M1-MCA) between 2013 and 2018. Median follow-up was 27.4 months (range 0-70.4). Binary logistic (alive at 3 months, OR <1) and Cox regression analyses were used to study the effect of MA and MD averages (MAavg and MDavg) on survival.

RESULTS

In Kaplan-Meier analysis, there was a significant inverse relationship with both MDavg and MAavg and mortality (MDavg P<0.001, MAavg P=0.002). Long-term mortality was 19.6% (n=61) and 3-month mortality 12.2% (n=38). In multivariable logistic regression analysis at 3 months, per 1-SD increase MDavg (OR 0.61, 95% CI 0.41 to 0.92, P=0.018:) and MAavg (OR 0.57, 95% CI 0.35 to 0.91, P=0.019) were the independent predictors associated with lower mortality. In Cox regression analysis, MDavg and MAavg were not associated with long-term survival.

CONCLUSIONS

In acute ischemic stroke patients, MDavg and MAavg are independent predictors of 3-month survival after MT of the ICA or M1-MCA. A 1-SD increase in MDavg and MAavg was associated with a 39%-43% decrease in the probability of death during the first 3 months after MT.

Carotid Artery Stenosis Is Associated with Better Intracranial Collateral Circulation in Stroke Patients

BACKGROUND

Adequate collateral circulation improves the clinical outcome of ischemic stroke patients. We evaluated the influence of ipsilateral carotid stenosis on intracranial collateral circulation in acute stroke patients.

METHODS

We collected the data of 385 consecutive acute stroke patients who underwent mechanical thrombectomy after multimodal computed tomography (CT) imaging in a single high-volume stroke center. Patients with occlusion of the first segment (M1) segment of the middle cerebral artery were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of carotid stenosis on intracranial collateral circulation was studied with appropriate statistical tests and ordinal regression analysis.

RESULTS

Fifty out of the 247 patients eligible for analysis had severe ipsilateral carotid stenosis (≥75%). These patients were 4-times more likely to have very good intracranial collaterals (Collateral Score 3-4, p = 0.001) than the nonstenotic and slightly stenotic (<75%) patients. The severely stenotic patients had a longer mean operation time (41 vs. 29 min to reperfusion, respectively, p = 0.001). Nevertheless, 54% of severely stenotic patients had good 3-month clinical outcome (modified Rankin Scale ≤2) with no significant difference between the 2 groups.

CONCLUSIONS

Carotid artery stenosis of over 75% of vessel diameter was associated with better intracranial collateral circulation of patients with acute ischemic stroke. This did not significantly change the 3-month clinical outcome.

Chronic Infarcts Predict Poor Clinical Outcome in Mechanical Thrombectomy of Sexagenarian and Older Patients

BACKGROUND

The impact of lacunar and cortical chronic ischemic lesions (CILs) on the clinical outcome of mechanical thrombectomy (MT) has been little studied. Clinical trials suggest that older patients benefit from MT. We investigated the effect of CILs on the clinical outcome of sexagenarian and older patients with acute middle cerebral artery (MCA) or distal internal carotid artery (ICA) stroke who received MT to treat large-vessel occlusion (LVO).

METHODS

We prospectively collected the clinical and imaging data of 130 consecutive MT patients of which 68 met the inclusion criteria. We limited the analysis to sexagenarian and older subjects and occlusions no distal than the M2 segment. Baseline clinical, procedural and imaging variables, technical outcome, 24-hour imaging outcome, and the clinical outcome were recorded. Differences between patients with and without CILs were studied with appropriate statistical tests and binary logistic regression analysis.

RESULTS

Twenty-one patients (31%) had at least 1 CIL. Thirty-eight percent of patients with CIL(s) compared with 62% without (P = .06) experienced good clinical outcome (3-month modified Rankin Scale ≤ 2). A similar nonsignificant trend was seen when lacunar lesions, lesion multiplicity, and chronic white matter lesions were examined separately. Absence of CIL increased the odds of good clinical outcome 3.7-fold (95% confidence interval 1.0-10.7, P = .05) in logistic regression modeling.

CONCLUSIONS

Chronic cortical and lacunar infarcts in admission imaging are associated with poor clinical outcome in sexagenarian and older patients treated with MT for LVO of the MCA or distal ICA.

Internal Carotid Artery and the Proximal M1 Segment Are Optimal Targets for Mechanical Thrombectomy

Background and Purpose

Mechanical thrombectomy (MT) is an established treatment of acute anterior circulation stroke caused by large vessel occlusion (LVO). We compared the clinical outcome (3-month modified Rankin Scale, mRS) in hyperacute (<3h from the onset of symptoms) ischemic stroke between an MT and an intravenous thrombolysis (IVT) cohort in proximal (ICA and the proximal M1 segment of the middle cerebral artery) and distal (the distal M1 and the M2 segment) LVOs.

Methods

We prospectively reviewed 67 patients who underwent MT with newer-generation stent retrievers. The IVT cohort consisted of 98 patients who received IVT without MT. We recorded baseline clinical, procedural and imaging variables, technical outcome, 24-h imaging outcome, and the clinical outcome. Differences between the groups were studied with theoretically appropriate statistical tests and binary logistic regression analysis.

Results

The proportion of patients who had a proximal LVO and experienced good (mRS ≤2) or excellent (mRS ≤1) clinical outcome was significantly larger in the MT group (62 vs. 7%, p < 0.001; 47 vs. 3%, p < 0.001, respectively). In a regression model including relevant confounding variables, good clinical outcome was seen significantly more often among patients with proximal occlusions (OR = 6.0, CI 95% 1.9-18.3, p = 0.002). In a similar model, no statistically significant differences were observed in patients with more distal occlusions.

Conclusions

MT is superior to IVT in achieving good clinical outcome in hyperacute anterior circulation stroke in the most proximal occlusions (ICA and proximal M1 segment). In the distal M1 and M2 segments neither of these therapies clearly outperforms the other.

TREVO and Capture LP have equal technical success rates in mechanical thrombectomy of proximal and distal anterior circulation occlusions

PURPOSE

Mechanical thrombectomy (MT) is a proven method to treat large vessel occlusions in acute anterior circulation stroke. We compared the technical, imaging, and clinical outcomes of MT performed with either TREVO or Capture LP devices.

METHODS

There were 42 and 43 patients in the TREVO and Capture LP groups, respectively. Baseline variables, technical outcome (Thrombolysis In Cerebral Infarction, TICI), 24 hours imaging outcome, and 3-month clinical outcome (modified Rankin Scale, mRS) were prospectively recorded. The patients were stratified according to clot location, groups compared, and logistic regression models devised to study the effect of device selection on the clinical outcome.

RESULTS

The technical success rates were equal in both proximal (internal carotid artery and proximal M1 segment) and distal occlusions (distal M1 and M2 segments). The proportion of TICI 2b or 3 was 96% and 87% with TREVO and 87% and 89% with Capture LP (p=0.25 and p=0.80, respectively). Device selection did not significantly predict good clinical outcome (mRS ≤2) in either proximal or distal occlusions. In multivariate analysis, selecting Capture LP borderline significantly increased the odds of an excellent outcome close to sixfold both in proximal and distal occlusions (OR 6.7, 95% CI 0.82 to 53.7, p=0.08 and OR 5.7, 95% CI 0.88 to 37.8, p=0.07, respectively).

CONCLUSIONS

TREVO and Capture LP perform equally well in proximal and distal occlusions in the anterior circulation when technical and good clinical outcome are considered. Capture LP may have a small advantage in reaching mRS ≤1 at 3 months. However, this needs to be confirmed in a randomized study.