Balloon-mounting stent versus balloon angioplasty for intracranial arterial stenosis: A systematic review and meta-analysis

BACKGROUND

Intracranial artery atherosclerotic stenosis (ICAS) is a major cause of stroke, especially in Asian countries. Current treatment options, including balloon-mounted stent (BMS) and balloon angioplasty (BA), lack sufficient evidence to determine a preferred approach. This systematic review and meta-analysis aimed to compare the efficacy and safety of BMS and BA in treating ICAS.

METHODS

Following PRISMA 2020 guidelines, we conducted a comprehensive search in PubMed, Web of Science, and Scopus up to December 1, 2023. Eligible studies compared BMS with BA in patients diagnosed with ICAS. Primary outcomes included the success rate and occurrence of stroke (ischemic or hemorrhagic). Secondary outcomes were perforator occlusion, in-stent thrombosis, death, and restenosis. Statistical analysis was conducted using R software version 4.3.1, employing a random-effects model.

RESULTS

Five high-quality studies involving 707 patients (515 males, 192 females) were included. BMS had a significantly higher success rate compared to BA (Risk Ratio [RR]: 1.13; CI: 1.03 to 1.24, p < 0.01; I2 = 14 %). The overall risk for stroke (ischemic and hemorrhagic) was significantly higher in BMS (RR: 2.97; CI: 1.32 to 6.67, p < 0.01; I2 = 0 %). However, no significant difference was found between BMS and BA regarding ischemic stroke (RR: 2.33; CI: 0.80 to 6.74, p = 0.12; I2 = 0 %). Additionally, no significant differences were observed in terms of perforator occlusion, in-stent thrombosis, dissection, minor and major strokes, and mortality rates. BMS was associated with a lower risk of restenosis (RR: 0.31; 95 % CI: 0.12 to 0.83, p = 0.02; I2 = 0 %).

CONCLUSION

Our results indicate that BMS might be associated with higher success and lower restenosis rates than BA in the treatment of ICAS but with an increased overall risk of stroke. No significant differences were observed in ischemic stroke, perforator occlusion, in-stent thrombosis, dissection, minor and major strokes, and mortality rates. The choice of treatment should consider these findings, alongside the technical challenges and desired angiographic outcomes. Future randomized controlled trials are necessary to further elucidate these results.

An Alternative Endovascular Technique for Treatment of Pulmonary Arteriovenous Malformation: Microballoon-occluded Transcatheter Embolization Using n-butyl-2-cyanoacrylate

PURPOSE

To investigate the safety and efficacy of microballoon-occluded transcatheter embolization using n-butyl-2-cyanoacrylate (NBCA) in patients with a single pulmonary arteriovenous malformation (PAVM).

METHODS

From November 2017 to November 2020, this retrospective study included 38 previously untreated patients with a single PAVM who underwent microballoon-occluded transcatheter embolization using NBCA. All 38 patients had follow-up that included simple chest radiography and contrast-enhanced chest computed tomography (CT).

RESULTS

A microballoon was successfully placed in a feeding artery of the PAVM to control the delivery of the NBCA cast in all 38 patients, with complete embolization of sacs and the feeding artery achieved in all cases. The mean diameters of the feeding artery, sac, and draining vein were 3.9 ± 0.9 mm, 7.5 ± 2.6 mm, and 4.6 ± 1.3 mm, respectively. A fixed 1:2 NBCA/Lipiodol ratio was used, and the mean amount of embolic mixture per patient was 1.4 mL (range 0.6-2.2 mL). There were no complications related to microballoon adhesion and non-target embolization of the systemic circulation. Follow-up CT in all 38 patients with a mean delay of 34.5 ± 8.8 months (range 20.7-56.5 months) showed no continued perfusion of the PAVM.

CONCLUSION

In our hands, microballoon-occluded n-butyl-2-cyanoacrylate embolization seemed to be safe and appeared to be clinically effective in patients with simple and complex types of single PAVM. Therefore, the present technique has the potential to become a standard treatment for a single PAVM.

Factors associated with successful balloon catheter labor induction in women with a previous caesarean section: A retrospective single-center evaluation

BACKGROUND

Labor induction of women with a history of uterine scarring is an increasingly frequent situation and one for which there are currently no clear professional recommendations favoring one method over another. The objectives of this study were to determine the success rate of balloon catheter induction in women with a history of caesarean section and to evaluate the main factors associated with vaginal delivery.

MATERIALS AND METHODS

This single-center retrospective study was conducted between January 1, 2014, and December 31, 2018, in Lille, France, and included all women with one previous caesarean section who were induced by first-line balloon catheter induction. Multivariate analysis was performed to identify the factors associated with the primary outcome (vaginal delivery).

RESULTS

Of the 310 women in the sample, 192 delivered vaginally (62 %). After adjustment, factors associated with successful induction (vaginal delivery) were the number of previous vaginal deliveries (odds ratio [OR] 1.37; 95 % confidence interval [CI] 1.04-1.81), evolution of the Bishop score after balloon removal (OR 1.24; 95 % CI 1.10-1.41), and the initial Bishop score (OR 1.17; 95 % CI 1.00-1.37). Uterine rupture was observed in three women (1 %).

CONCLUSION

The vaginal delivery rate after balloon catheter induction in women with a previous caesarean section was 62 %. Prognostic factors for vaginal delivery include previous vaginal delivery, the initial Bishop score, and evolution of the Bishop score after balloon catheter induction.

Posterior wall isolation via a multi-electrode radiofrequency balloon catheter: feasibility, technical considerations, endoscopic findings and comparison with cryoballoon technologies

BACKGROUND

Posterior wall (PW) isolation is an important adjunctive ablation target in patients with non-paroxysmal atrial fibrillation (AF). Traditionally performed with point-by-point radiofrequency (RF) ablation, PW isolation has also been performed with different cryoballoon technologies. We aimed at assessing the feasibility of PW isolation with the novel RF balloon catheter Heliostar™ (Biosense Webster, CA, USA).

METHODS

We prospectively enrolled 32 consecutive patients with persistent AF scheduled for first-time ablation with the Heliostar™ device. Procedural data were compared with those from 96 consecutive persistent AF patients undergoing pulmonary vein (PV) plus PW isolation with a cryoballoon device. The ratio RF balloon/cryoballoon was 1:3 for each operator involved in the study, aiming at avoiding any imbalance related to different experience.

RESULTS

Single-shot PV isolation was documented in a significantly higher number of cases with the RF balloon technology compared to cryoballoon ablation (89.8% vs. 81.0%; p = 0.02, respectively). PW isolation was achieved with a similar number of balloon applications between the two groups (11 ± 4 with the RF balloon versus 11 ± 2 with the cryoballoon; p = 0.16), but in a significantly shorter time among RF balloon patients (228 ± 72 s versus 1274 ± 277 s with cryoballoon; p < 0.001). Primary safety endpoint occurred in none of the RF balloon patients versus 5 (5.2%) patients in the cryoballoon group (p = 0.33). Primary efficacy endpoint was achieved in all (100%) RF balloon patients versus 93 (96.9%) cryoballoon ones (p = 0.57). Oesophageal endoscopy did not show any signs of thermal lesions in RF balloon patients with luminal temperature rise.

CONCLUSIONS

RF balloon-based PW isolation was safe and promoted shorter procedure times compared to similar cryoballoon-based ablation procedures.

Percutaneous balloon-assisted ultrasound-guided direct thrombin embolization of superficial femoral artery pseudoaneurysm: a case series and literature review

BACKGROUND

Superficial femoral artery (SFA) pseudoaneurysms, a rare but potentially life-threatening complication, that can arise after vascular interventions or trauma. This case series explores the efficacy and safety of a minimally invasive treatment modality, percutaneous ultrasound-guided thrombin injection (PUGTI) combined with balloon occlusion, in three patients with SFA pseudoaneurysms.

CASE PRESENTATION

Three patients (age: 71-82 years; 3 female) with SFA pseudoaneurysms underwent PUGTI with balloon occlusion. The procedure involved direct thrombin injection under ultrasound guidance while occluding the parent artery using a balloon catheter. Follow-up was conducted at 1 week and 1 month post-procedure to assess technical success, complications, and recurrence.

CONCLUSION

PUGTI combined with balloon occlusion appears to be a safe and effective treatment for SFA pseudoaneurysms, particularly for larger pseudoaneurysms. The procedure is associated with a high technical success rate. Balloon occlusion may offer a safer alternative to direct thrombin injection without occlusion, as it potentially minimizes the risk of complications such as distal thromboembolism.

From celebration to contamination: Analysing microplastics released by burst balloons

Air balloons are a ubiquitous presence in our daily lives, and their rupture may release a substantial quantity of debris, as investigated herein. We employ Raman imaging to capture the fragments resulting from balloon explosions, enabling the identification and direct visualisation of minute microplastic particles / fragments with an improved signal-to-noise ratio for precise quantification. To circumvent the generation of misleading confocal Raman images, we recommend employing terrain mapping to scan the three-dimensional surface of the sample. It is important to acknowledge that the analysis of microplastics at the micro-scale inherently poses limitations in terms of throughput, as it necessitates a trade-off between low and high magnifications. We conduct explosive experiments on ten-to-hundred balloons, collecting debris from various angles and positions. Our investigation involves the random testing of multiple samples / sample positions at the micro-scale, with subsequent extrapolation to estimate the total amount of microplastics. The amalgamation of these results through statistical analysis indicates that each balloon explosion can potentially release tens-to-thousands of microplastics, highlighting a concern that has hitherto received insufficient attention. The characterisation approach, particularly the random Raman scanning method in combination with SEM and the statistical analysis on accumulated samples employed in this report, has the potential to serve as a useful tool in future research on microplastics and even nanoplastics.

SAFETY OF ENDOSCOPIC ULTRASONOGRAPHY LATEX BALLOON USE IN PATIENTS WITH A LATEX ALLERGY

BACKGROUND AND AIMS

Balloons are used in endoscopic ultrasonography (EUS) to improve visualization. However, data on the safety of latex balloons in patients with latex allergies is limited, and non-latex alternatives can be costly. We aimed to investigate the safety of latex balloon use during EUS.

METHODS

A retrospective review was conducted at a tertiary center between 2019-2022. Patients with reported latex allergies who underwent linear EUS were included. Baseline demographics, EUS characteristics, and adverse events were collected. The primary outcome was the rate of adverse events.

RESULTS

87 procedures were performed on 57 unique patients (mean age 65.3± 14.5 years). Latex balloons were used in 59 procedures (67.8%), with only 8 procedures (13.6%) using prophylactic medications. No adverse events occurred during or after procedures, regardless of medication use or history of anaphylaxis.

CONCLUSIONS

The use of EUS latex balloons in patients with a latex allergy was associated with no adverse events.

Modified procedure for reconstructing the inferomedial orbital wall: silicone sheet implantation without surgical removal

BACKGROUND

Due to the complexity of reconstructing wide inferomedial orbital wall fractures, silicone sheets are the preferred choice of reconstructive material. Nevertheless, it is crucial to remove the silicone sheet postoperatively due to the risk of delayed complications associated with its placement.

METHODS

We developed a procedure in which a silicone sheet implanted in the orbit can be extracted through the nasal cavity by removing the fractured portion of the medial orbital wall.

CONCLUSION

This procedure enables the utilization of silicone sheets, which are suitable for intricate orbital reconstruction, without any concerns regarding delayed complications.

Comparison of drug-coated balloon with conventional balloon for angioplasty in symptomatic intracranial atherosclerotic stenosis

BACKGROUND

Drug-coated balloon (DCB) angioplasty has been studied for reducing the occurrence of restenosis after treatment for intracranial atherosclerotic stenosis (ICAS), but no comparison has been published of the use of drug-coated and non-coated balloons in angioplasty for ICAS. We aim to compare the safety and efficacy of DCB angioplasty with conventional balloon (CB) angioplasty for the treatment of symptomatic ICAS.

METHODS

One hundred cases with symptomatic ICAS treated with DCB (n=49) and CB (n=51) angioplasty were retrospectively analyzed. 1:1 propensity score matching (PSM) was completed to eliminate bias in the patients selected for further analysis. The periprocedural events and follow-up outcomes between the two groups were compared.

RESULTS

There were 32 cases in each group after PSM. Technical success (<50% residual stenosis) was achieved in 30 cases (93.8%) in the DCB group and in 28 cases (87.5%) in the CB group. The rates of stroke or mortality within 30 days were 3.1% in the DCB group and 6.3% in the CB group (p=1). The incidence of restenosis in the DCB group (6.3%) was significantly lower than that in the CB group (31.3%) (p=0.01).

CONCLUSIONS

Compared with CB angioplasty, DCB angioplasty can effectively reduce the incidence of restenosis. Further studies are needed to validate the role of DCB angioplasty in the management of symptomatic ICAS.

Prevention of in-stent restenosis with drug-eluting balloons in patients with postirradiated carotid stenosis accepting percutaneous angioplasty and stenting

OBJECTIVE

To investigate the technical safety and outcome of in-stent restenosis (ISR) prevention with drug-eluting balloon (DEB) in patients with postirradiated carotid stenosis (PIRCS) undergoing percutaneous angioplasty and stenting (PTAS).

METHODS

Between 2017 and 2021, we prospectively recruited patients with severe PIRCS for PTAS. They were randomly separated into two groups based on endovascular techniques performed with and without DEB. Preprocedural and early postprocedural (within 24 hours) MRI, short-term ultrasonography (6 months after PTAS), and long-term CT angiography (CTA)/MR angiography (MRA), 12 months after PTAS, were performed. Technical safety was evaluated based on periprocedural neurological complications and the number of recent embolic ischemic lesions (REIL) in the treated brain territory on diffusion-weighted imaging of early postprocedural MRI.

RESULTS

Sixty-six (30 with and 36 without DEB) subjects were enrolled, with one failure in techniques. For 65 patients in the DEB versus conventional groups, technical neurological symptoms within 1 month (1/29 (3.4%) vs 0/36; P=0.197) and REIL numbers within 24 hours (1.0±2.1 vs 1.3±1.5; P=0.592) after PTAS showed no differences. Peak systolic velocity (PSVs) on short-term ultrasonography was significantly higher in the conventional group (104.13±42.76 vs .81.95±31.35; P=0.023). The degree of in-stent stenosis (45.93±20.86 vs 26.58±8.75; P<0.001) was higher, and there were more subjects (n=8, 38.9% vs 1, 3.4%; P=0.029) with significant ISR (≥ 50%) in the conventional group than in the DEB group on long-term CTA/MRA.

CONCLUSIONS

We observed similar technical safety of carotid PTAS with and without DEBs. The number of cases of significant ISR were fewer and the degree of stenosis of ISR was less in primary DEB-PTAS of PIRCS than for conventional PTAS in the 12-month follow-up.

First experience with Walrus balloon guide catheter in a whole-body flow model

PURPOSE

Flow arrest using a balloon guide catheter (BGC) in mechanical thrombectomy (MT) due to large vessel occlusion has been associated with better outcomes. Known limitations of currently commercially available BGCs are incompatibility with large bore aspiration catheters (AC) and lack of distal flexibility. Walrus presents variable stiffness and compatibility with large bore AC. The goal of this study is to describe the first experience with Walrus in a realistic stroke simulation model.

METHODS

A full-length modular vascular model under physiological conditions was used. 8F+-Walrus inner-diameter (ID) 0.087in 95 cm combined with 6F-Sofia AC ID 0.070in 131 cm and an 8F-Flowgate2 BGC ID 0.084in 95 cm with a 5F-Sofia AC ID 0.055in 125 cm were used to perform aspiration MT. User surveys, access to target and occlusion site, technique, time of delivery, anatomical change, and catheter kick-back were assessed.

RESULTS

Seven neuroradiologists with average of 10 years-experience in MT performed primary aspiration using the above-mentioned combinations in three different anatomies (N = 41). All operators would likely (29%) or very likely (71%) use again Walrus in combination with large bore AC and the majority (86%) found its navigability easier than with other BGCs. Time to reach final BGC position and catheter kick-back did not differ significantly among anatomies or catheter combinations (p > 0.05). However, Walrus was more likely to reach ICA petrous segment (p < 0.05) and intracranial occlusion with AC (p < 0.01).

CONCLUSION

The Walrus combined with large bore AC presented significantly better distal access and navigability for primary aspiration in an in vitro stroke model.

Direct puncture embolization of a medulla oblongata hemangioblastoma

Hemangioblastoma is a rare tumor of vascular origin, most commonly located in the posterior fossa, which presents with severe symptoms and usually very hard to resect without remarkable operative blood loss.1-2 Pre-operative embolization may decrease the amount of intra-operative bleeding, but the endovascular treatment of such tumor may be very challenging due to the high risk of infarction of the surrounding tissues. Direct puncture embolization has been developed to overcome many of the limitations of endovascular techniques for many hypervascular lesions, also hemangioblastomas.3-5 We present in this Technical Video (video 1) a direct puncture embolization with balloon-protection of a hemangioblastoma of the medulla oblongata using Onyx 18 (Medtronic, inc.) as sole liquid embolic agent.

Comparison of balloon guide catheter versus non-balloon guide catheter for mechanical thrombectomy in patients with distal medium vessel occlusion

BACKGROUND

Several studies have established the safety and efficacy of balloon guide catheters (BGCs) for large vessel occlusions. However, the utility of BGCs remains largely unexplored for distal medium vessel occlusions (DMVOs). In this study, we aim to compare the outcomes of BGC vs. Non-BGC in patients undergoing mechanical thrombectomy (MT) for DMVO.

METHOD

This retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) encompassed adult patients with acute anterior cerebral artery, posterior cerebral artery, and middle cerebral artery-M2-3-4 occlusions. Procedure times, safety, recanalization, and neurological outcomes were compared between the two groups, with subgroup analysis based on first-line thrombectomy techniques.

RESULTS

A total of 1508 patients were included, with 231 patients (15.3%) in the BGC group and 1277 patients (84.7%) in the non-BGC group. The BGC group had a lower modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2C (43.2% vs 52.7%, P=0.01), longer time from puncture to intracranial access (15 vs 8 min, P<0.01), and from puncture to final recanalization (97 vs 34 min, P<0.01). In the Solumbra subgroup, the first pass effect (FPE) rate was lower in the BGC group (17.4% vs 30.7%, P=0.03). Regarding clinical outcomes, the BGC group had a lower rate of distal embolization (8.8% vs 14.9%, P=0.03).

CONCLUSION

Our study found that use of BGC in patients with DMVO was associated with lower mTICI scores, decreased FPE rates, reduced distal embolization, and longer procedure times.

Safety and efficacy of drug coated balloon angioplasty for intracranial atherosclerotic disease

BACKGROUND

Drug coated balloon (DCB) angioplasty can provide sustained anti-restenotic efficacy without the limitations of permanent vascular implantation and is presumably ideal for treating intracranial atherosclerotic disease. However, the safety of paclitaxel in the neurovasculature remains a concern.

METHODS

242 patients with angiographically verified symptomatic stenosis >70% in intracranial arteries treated with DCB angioplasty were reviewed divided into two groups: group A, patients with stenotic intracranial arteries; and group B, patients with acute, subacute, or chronic occluded intracranial arteries. The primary endpoint was any stroke or death within 30 days. The secondary endpoint was arterial restenosis of >50% during follow-up.

RESULTS

16 major and 12 minor complications occurred among 245 procedures (6.5% and 4.9%, respectively). Five patients died within 30 days after the procedure (2.1%, 5/242). 12 major and 12 minor complications occurred among 211 procedures in group A (5.7% and 5.7%). In group B, four major complications occurred among 34 procedures (11.8%). Hyperperfusion and perforator stroke accounted for half of all complications (53.6%, 15/28). Restenosis >50% was present in eight lesions during the follow-up period (4.8%, 8/167).

CONCLUSIONS

After treatment with DCB angioplasty, complications were no different from those after standard balloon angioplasty or stenting. This study suggests that DCB angioplasty may be a safe and effective procedure for intracranial arterial stenosis.

Robotic-guided direct transtemporal embolization of an indirect carotid cavernous fistula

A middle-aged patient presented with right-sided chemosis, exophthalmos, and progressive visual loss. Digital subtraction angiography revealed a type D carotid-cavernous fistula (CCF). Transarterial embolization through the internal maxillary artery was unsuccessful, and there was no venous access to the CCF. A robotic-guided direct transtemporal embolization of the CCF with Onyx was performed, resulting in successful fistula obliteration and symptom resolution. This is the first reported case of a robotic-guided direct transcranial CCF embolization. We include a technical video that demonstrates this procedure (Supplemental File 1).

Drug-coated balloon for treatment of non-atherosclerotic renal artery stenosis-a multi-center study

INTRODUCTION

Renal artery stenosis (RAS) is a significant reason for secondary hypertension. Impaired renal function and subsequent cardiopulmonary dysfunction could also occur. Patients of non-atherosclerotic RAS has a relatively young age and long life expectancy. Revascularization with percutaneous transluminal angioplasty (PTA) is a viable treatment option. However, restenosis is unavoidable which limits its use. Drug-coated balloon (DCB) has been proven to be effective in restenosis prevention in femoropopliteal arterial diseases and in patients with renal artery stenosis. And PTA for Renal artery fibromuscular dysplasia is safe and clinically successful. Therefore, we could speculate that DCB might have potential efficacy in non-atherosclerotic RAS treatment.

METHODS AND ANALYSIS

This will be a randomized multi-center-controlled trial. Eighty-four eligible participants will be assigned randomly in a 1:1 ratio to the control group (plain old balloon, POB) and the experimental group (DCB). Subjects in the former group will receive balloon dilatation alone, and in the latter group will undergo the DCB angioplasty. The DCB used in this study will be a paclitaxel-coated balloon (Orchid, Acotec Scientific Holdings Limited, Beijing, China). Follow-up visits will be scheduled 1, 3, 6, 9, and 12 months after the intervention. Primary outcomes will include controlled blood pressure and primary patency in the 9-month follow-up. Secondary outcomes will include technical success rate, complication rate, and bail-out stenting rate.

TRIAL REGISTRATION

ClinicalTrials.gov (number NCT05858190). Protocol version V.4 (3 May 2023).

Matched-pair analysis of patients with ischemic stroke undergoing thrombectomy using next-generation balloon guide catheters

BACKGROUND

Balloon guide catheters (BGCs) have not been widely adopted, possibly due to the incompatibility of past-generation BGCs with large-bore intermediate catheters. The next-generation BGC is compatible with large-bore catheters. We compared outcomes of thrombectomy cases using BGCs versus conventional guide catheters.

METHODS

We conducted a retrospective study of 110 thrombectomy cases using BGCs (n=55) and non-BGCs (n=55). Sixty consecutive thrombectomy cases in whom the BOBBY BGC was used at a single institution between February 2021 and March 2022 were identified. Of these, 55 BGC cases were 1:1 matched with non-BGC cases by proceduralists, age, gender, stent retriever + aspiration device versus aspiration-only, and site of occlusion. First-pass effect was defined as Thrombolysis In Cerebral Infarction 2b or higher with a single pass.

RESULTS

The BGC and non-BGC cohorts had similar mean age (67.2 vs 68.9 years), gender distribution (43.6% vs 47.3% women), median initial National Institutes of Health Stroke Scale score (14 vs 15), and median pretreatment ischemic core volumes (12 mL vs 11.5 mL). BGC and non-BGC cases had similar rates of single pass (60.0% vs 54.6%), first-pass effect (58.2% vs 49.1%), and complications (1.8% vs 9.1%). In aspiration-only cases, the BGC cohort had a significantly higher rate of first-pass effect (100% vs 50.0%, p=0.01). BGC was associated with a higher likelihood of achieving a modified Rankin Scale score of 2 at discharge (OR 7.76, p=0.02). No additional procedural time was required for BGC cases (46.7 vs 48.2 min).

CONCLUSION

BGCs may be safely adopted with comparable procedural efficacy, benefits to aspiration-only techniques, and earlier functional improvement compared with conventional guide catheters.

Retinal artery/arteriole occlusion risks after endovascular treatment for unruptured intracranial aneurysm

BACKGROUND

To evaluate the association between retinal artery/arteriole occlusion (RAO) and unruptured intracranial aneurysm (UIA).

METHODS

Incident UIA patients from a nationwide cohort (n=253 240) were categorised into three groups based on subsequent treatment: observation (n=208 993), microsurgical clipping (n=14 168) and endovascular treatment (EVT) groups (n=30 079). The incidence and the incident time of RAO were analysed. HRs of RAO and associated risk factors were evaluated. Additionally, a hospital cohort comprising 2569 consecutive UIA patients treated at a tertiary hospital was analysed with detailed clinical information of UIAs.

RESULTS

In the nationwide cohort analysis, the incidence of RAO was significantly higher in EVT group than in observation and clipping groups, especially within 60 days (early RAO (within 60 days): HR=4.00, 95% CI: 2.44 to 6.56); delayed RAO (after 60 days): HR=1.74, 95% CI: 1.13 to 2.68). Multivariable analysis showed that the presence of chronic kidney disease (p=0.009) and use of a balloon microcatheter during the procedure (p=0.013) were associated with a higher risk of RAO. In hospital cohort analysis, 11 (0.8%) cases of RAO occurred after EVT, whereas none occurred after microsurgical clipping (p<0.001). Patients with RAO were younger and received balloon microcatheters more frequently than their counterparts. Ten cases of RAO (90.9%) occurred in paraclinoid aneurysms, where EVT was preferred over microsurgical clipping.

CONCLUSIONS

Performing EVT for UIA may increase the risk of subsequent RAO. Care should be taken when treating paraclinoid aneurysms with balloon microcatheters.

Cerebrovascular pulsatile tinnitus: causes, treatments, and outcomes in 164 patients with neuroangiographic correlation

BACKGROUND

Pulsatile tinnitus (PT) can cause significant detriment to quality of life and may herald a life-threatening condition. Endovascular evaluation is the gold standard for the definitive diagnosis of PT and facilitates treatment. However, no large study has determined the distribution of causes and treatment outcomes of PT evaluated endovascularly.

METHODS

Consecutive patients evaluated at a multidisciplinary PT clinic from a single academic center were retrospectively reviewed. Patients with a suspected cerebrovascular etiology of PT based on clinical and/or non-invasive imaging, who were evaluated by endovascular techniques (arteriography, venography, manometry, and/or balloon test occlusion), were included in analysis. Baseline clinical features and treatment results by final etiology of PT were compared.

RESULTS

Of 552 patients referred for PT evaluation, 164 patients (29.7%) who underwent endovascular evaluation of PT were included. Mean (±SD) age at first clinical evaluation was 54.3±14.1 years (range 25-89 years); 111 patients (67.7%) were female. PT causes were 75.6% vascular and 24.4% non-vascular. Arteriovenous shunting lesions caused 20.7% of cases, venous etiologies 48.2%, and arterial etiologies 6.7%. Of patients with a shunting lesion treated with endovascular embolization, 96.9% had lasting significant improvement or resolution in PT. Endovascular stenting for venous sinus stenosis gave 84.6% of patients lasting improvement or resolution in PT. Arterial and non-vascular PT had fewer patients treated endovascularly and less improvement in PT symptoms.

CONCLUSION

PT with a suspected vascular cause is most often attributable to venous etiologies. PT caused by arteriovenous shunting or venous sinus stenosis may be effectively treated endovascularly.

Losing weight to achieve joint or hernia surgery: is the intragastric balloon the answer?

BACKGROUND

Obesity is an epidemic, with its accompanying medical conditions putting patients at increased risk of postoperative complications. For patients undergoing elective surgery, preoperative weight loss provides an opportunity to decrease complications. We sought to evaluate the safety and efficacy of an intragastric balloon in achieving a body mass index (BMI) < 35 kg/m2 prior to elective joint replacement or hernia repair.

METHODS

Retrospective review of all patients who had intragastric balloon placement at a level 1A VA medical center from 1/2019 to 1/2023. Patients who had a scheduled qualifying procedure (knee/hip replacement or hernia repair) and had a BMI > 35 kg/m2 were offered intragastric balloon placement to achieve 30-50lbs (13-28 kg) weight loss prior to surgery. Participation in a standardized weight loss program for 12 months was required. Balloons were removed 6 months after placement, preferentially concomitant with the qualifying procedure. Baseline demographics, duration of balloon therapy, weight loss and progression to qualifying procedure were recorded.

RESULTS

Twenty patients completed intragastric balloon therapy and had balloon removal. Mean age 54 (34-71 years), majority (95%) male. Mean balloon duration was 200 ± 37 days. Mean weight loss was 30.8 ± 17.7lbs (14.0 ± 8.0 kg) with an average BMI reduction of 4.4 ± 2.9. Seventeen (85%) patients were successful, 15 (75%) underwent elective surgery and 2 (10%) were no longer symptomatic after weight loss. Three patients (15%) did not lose sufficient weight to qualify or were too ill to undergo surgery. Nausea was the most frequent side effect. One (5%) patient was readmitted within 30 days for pneumonia.

DISCUSSION

Intragastric balloon placement resulted in an average 30lbs (14 kg) weight loss over 6 months allowing more than 75% of patients to undergo joint replacement or hernia repair at an optimal weight. Intragastric balloons should be considered in patients requiring 30-50lbs (13-28 kg) weight loss prior to elective surgery. More study is needed to determine the long-term benefit of preoperative weight loss prior to elective surgery.

In-stent restenosis after vertebral artery origin stenosis stenting: a nomogram for risk assessment

OBJECTIVE

To propose a nomogram for individual risk assessment of in-stent restenosis (ISR) after vertebral artery origin stenosis (VAOS) stenting.

METHODS

We included 793 patients with VAOS treated with stenting from October 2006 to May 2013, with a median follow-up of 27.8 months. Cox regression and the least absolute shrinkage and selection operator (LASSO) regression were adopted for variable selection. The nomogram was formulated and validated by concordance indexes (C-indexes) and calibration curves. An in-stent restenosis risk table (ISR-RT) was subsequently generated for risk stratification. Differences between low-, intermediate-, and high-risk levels were shown by Kaplan-Meier curves and compared by log-rank test.

RESULTS

The training and validation set included 594 and 199 patients, with a mean ISR rate of 37.2% and 35.2%, respectively. Stent type (HR=1.64, 95% CI 1.26 to 2.14), stent diameter (HR=2.48, 95% CI 1.77 to 3.48), history of peripheral vascular disease (HR=2.17, 95% CI 1.17 to 4.00), history of transit ischemic attack (HR=1.45, 95% CI 1.05 to 2.14), and left-side involvement (HR=1.33, 95% CI 1.04 to 1.69) were included in the nomogram. The C-indexes at 6 and 12 months were 0.650 and 0.611 in the training set, and 0.713 and 0.603 in the validation set, respectively. Compared with low-risk patients, the intermediate- and high-level group had 1.46 (95% CI 1.05 to 2.04; p=0.0235) and 2.28 (95% CI 1.64 to 3.17; p<0.0001) higher chances of developing ISR in 2 years, respectively.

CONCLUSIONS

A nomogram and a risk evaluation table were developed with good predictive ability for in-stent restenosis among patients with VAOS, which could serve as a practical approach for individualized risk evaluation.

'Pressure cooker' and 'balloon pressure' techniques significantly increase 3-month complete occlusion rate after spinal arteriovenous fistula embolization as compared to glue: single center evaluation on 38 consecutive patients

BACKGROUND

Spinal arteriovenous fistulas can be treated either by surgery or by endovascular means, using different strategies. The main drawback of embolization is the risk of recurrence. Our objective is to evaluate the angiographic occlusion rate and the predictive factors of angiographic cure of spinal arteriovenous fistulas at 3 months or more after embolization.

METHODS

This is a retrospective single-center study including 38 consecutive patients with spinal arteriovenous fistulas treated by embolization as first-line treatment. We reviewed clinical and imaging data, complications, and the immediate angiographic occlusion rate of the fistulas, and at 3 months or more after the embolization.

RESULTS

A total of 45 embolization procedures were performed: 30 procedures using glue, 15 using Onyx by 'pressure cooker' or 'balloon pressure' techniques. We observed no statistically significant difference between the two groups concerning the immediate angiographic occlusion rate (87% in both groups; P>0.9), as well as for periprocedural complication rates. The angiographic occlusion rate at 3 months or more was higher in the Onyx 'combined' techniques treated group (87% vs 40%, P=0.007). The use of Onyx 'combined' techniques was independently associated with angiographic cure at 3 months after embolization (P=0.029). No other factors were identified as predictive of angiographic cure and clinical recovery after embolization procedures, nor were any predictive factors identified for the occurrence of periprocedural complications.

CONCLUSION

Embolization of spinal arteriovenous fistulas with Onyx using 'combined' techniques appears to be safe and associated with a higher rate of angiographic occlusion at 3 months than regular embolization with glue.

Balloon angioplasty versus stent placement for the treatment of portal vein stenosis in children: a single center experience

PURPOSE

To evaluate the safety and efficacy of percutaneous interventional treatment of portal vein stenosis in children.

MATERIAL AND METHODS

A retrospective analysis of all interventional treatments for portal vein stenosis in pediatric patients at a single institution from 2010 to 2021 was conducted. Platelet count, spleen size and portal vein flow velocity were assessed during the follow-up period. Primary and primary assisted patency time were determined.

RESULTS

A total of ten children (median age 28.5 months, interquartile range (IQR): 2.75-52.5 months) with portal vein stenosis after Mesorex-Shunt (n = 4), liver transplantation (n = 3) and other etiologies (n = 3) underwent 15 interventional procedures. There were five reinterventions and one discontinued intervention. The technical success rate was 93.3% (14/15) and clinical success of treated patients was 100% (14/14). Median follow-up was 18 months (IQR: 13.5-81 months). The median primary patency time for stent placement was 70 months (IQR: 13.5-127.25 months). For balloon angioplasty, the median primary patency time was 9 months (IQR 7.25-11.5 months), while the median assisted primary patency time was 14 months (IQR: 12 to 15 months). Platelet count, spleen size and portal vein flow velocity reliably corresponded to recurrence of portal vein stenosis in asymptomatic patients during follow-up.

CONCLUSION

Interventional treatment is a safe and efficient method to treat portal vein stenosis with long patency times, regardless of etiology. Primary stent placement shows a higher primary patency time than balloon angioplasty. Implementation of stent placement as the primary interventional method may improve patency times and reduce the need for repeat reinterventions in pediatric patients.

Transvenous balloon-assisted approach to anterior fossa dural arteriovenous fistula using retrograde pressure cooker technique

Endovascular embolization is the first-line therapy for dural arteriovenous fistulas (dAVFs). Transarterial embolization (TAE) may be limited by poor anatomical access. Transvenous embolization avoids this, but carries a risk of hemorrhage, venous redirection, and neurologic deterioration. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA, USA) provide flow arrest and prevent reflux during TAE with liquid embolic agents (LEAs), but use in the distensible veins may be challenging. In this video, we use a Scepter Mini in a transvenous approach to a Cognard type IV anterior ethmoidal dAVF as a safe alternative to surgery, transvenous pressure cooker, and trans-ophthalmic TAE (video 1). The Scepter Mini was navigated transvenously to the anterior superior sagittal sinus. LEA was injected with excellent penetration to the venous pouch and further penetration into the network of tortuous feeders. No neurologic complications were experienced, and follow-up angiogram 9 months later demonstrated cure of the dAVF. Video 2 describes procedural considerations in transvenous approaches, steps of the procedure, and includes references1-10 which are relevant to this topic.neurintsurg;jnis-2023-020530v1/V1F1V1Video 1 neurintsurg;jnis-2023-020530v1/V2F2V2Video 2 .

Transarterial embolization for anterior cranial fossa dural arteriovenous fistulas: a retrospective single-center study

BACKGROUND

Clip ligation of anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs) is the traditionally accepted first-line treatment. Endovascular treatment for ACF DAVFs may achieve good outcomes as endovascular techniques advance. Here we report the clinical and angiographic outcomes in patients with ACF DAVFs who underwent transarterial embolization (TAE) as first-line treatment.

METHODS

Over a 20-year period, 87.0% (40/46) of patients received TAE as first-line treatment. The clinical presentation, angiographic features, treatment strategy, and clinical and angiographic outcomes are described in this article.

RESULTS

Forty patients underwent TAE as first-line treatment. There were 36 men and 4 women, with a mean age of 55.6 (55.6±7.4) years. A total of 64 embolization attempts were performed. The middle meningeal artery (66.7%, 12/18) and the ophthalmic artery (54.2%, 13/24) were the most frequently used arterial access routes for complete embolization. The second option was the sphenopalatine artery (46.7%, 7/15). Complications, that is, retinal ischemia, occurred in one patient (2.5%). The total immediate complete occlusion rate for TAE was 82.5% (33/40). Two patients needed surgery for incomplete embolization. When followed up (90%, 36/40), one patient (2.8%, 1/36) reported worsening symptoms due to retinal ischemia following TAE. Although fewer than 50% of the patients received digital subtraction angiography follow-up, there were no recurrences.

CONCLUSIONS

We show that TAE is safe and effective in the treatment of ACF DAVFs in this study of 40 patients, making it a viable alternative to surgical ligation and transvenous embolization. More research is needed to compare these various treatment modalities.

The utility of balloon dilation for piriform aperture stenosis - A first line surgical treatment

AIM

Describe the long-term outcomes of patients with piriform aperture stenosis managed with balloon dilation.

METHODS

Review of current literature. A retrospective case series of 6 patients with piriform aperture stenosis initially managed with balloon dilation at a tertiary paediatric hospital.

RESULTS

Six neonates diagnosed with piriform aperture were managed with balloon dilation under general anaesthesia after failing conservative treatment. Average age at first dilation was 28 days old (range 6-54). The piriform aperture was an average width of 5.15 mm, with a 4-6.5 mm range, as measured on axial CT scan. The average width at 25% of the nasal cavity, 50% and 75% was 7.7 mm, 9.3 mm and 9.98 mm respectively. Four neonates required only a single balloon dilation - two of these were stented post-operatively. The remaining two neonates required multiple balloon dilations with eventual drill-out through a sublabial approach. There was a trend of smaller piriform and nasal cavity diameters in those who required multiple procedures. The mean follow-up was 30 months.

CONCLUSION

Balloon dilation should be considered for primary operative management in neonates with piriform aperture stenosis who fail medical interventions. Balloon dilation can treat the narrowing at and beyond the piriform aperture. Patients who require more than one dilation are more likely to have a smaller piriform aperture and may need a drill-out procedure. The impact of nasal stents on outcomes is unclear.

Long-Term Clinical Outcomes of Drug-Coated Balloon Treatment for De Novo Coronary Lesions

PURPOSE

Data are limited on the long-term efficacy and safety of drug-coated balloon (DCB) treatment in comparison to drug-eluting stent (DES) for de novo coronary lesions. We investigated the long-term clinical outcomes of DCB treatment in percutaneous coronary intervention (PCI) for de novo coronary lesions.

MATERIALS AND METHODS

A total of 103 patients scheduled for elective PCI for de novo non-small coronary lesions (≥2.5 mm) who were successfully treated with DCB alone were retrospectively compared with 103 propensity-matched patients treated with second-generation DES from the PTRG-DES registry (n=13160). All patients were followed for 5 years. The primary endpoint was major adverse cardiac events [MACE; cardiac death, myocardial infarction, stroke, target lesion thrombosis, target vessel revascularization (TVR), and major bleeding] at 5 years.

RESULTS

At 5-year clinical follow-up, Kaplan-Meier estimates of the rate of MACE were significantly lower in the DCB group [2.9% vs. 10.7%; hazard ratio (HR): 0.26; 95% confidence interval (CI): 0.07-0.96; log-rank p=0.027]. There was a significantly lower incidence of TVR in the DCB group (1.0% vs. 7.8%; HR: 0.12; 95% CI: 0.01-0.98; long-rank p=0.015), and there was major bleeding only in the DES group (0.0% vs. 1.9%; log-rank p=0.156).

CONCLUSION

At 5-year follow-up, DCB treatment was significantly associated with reduced incidences of MACE and TVR, compared with DES implantation, for de novo coronary lesions.

Efficacy and safety in patients treated with a novel radiofrequency balloon: a two centres experience from the AURORA collaboration

AIMS

A novel irrigated radiofrequency (RF) balloon (RFB) for pulmonary vein (PV) isolation (PVI) was released in selected centres. We pooled the procedural data on efficacy and safety of RFB-PVI from two high volume German centres.

METHODS AND RESULTS

Consecutive patients with RFB procedures were enrolled. A 3D electroanatomical left atrial map guided the RFB navigation. Every RF delivery lasted 60 s, and duration was automatically reduced to 20 s for electrodes facing the posterior wall. Procedural data and post-procedural endoscopy data (<48 h) were analysed. Data from 140 patients were collected (57% male, 67 ± 11 years, 57% paroxysmal atrial fibrillation). There were 547 PVs identified, and 99.1% could be isolated using solely the RFB. Single-shot PVI was recorded in 330/547 (60%) PVs. Median time to isolation during the first application was 10 s (IQR 8-13). A total of 2.1 ± 1.8 applications per PV were delivered, with the left superior PV requiring more application compared to other PVs. Median procedure and fluoroscopy time were 77 min (61-99) and 13 min (10-17), respectively. Major safety events were recorded only in the first 25 cases at each centre and included 1/140(0.7%) cardiac tamponade, 1/140(0.7%) phrenic nerve palsy, and 2/140 strokes (1.4%). An oesophageal temperature rise was recorded in 81/547 (15%) PVs, and endoscopy detected oesophageal lesions in 7/85 (8%) patients undergoing endoscopy.

CONCLUSION

The RFB showed a high efficacy allowing for fast PVI procedures, and 60% of PVs could be isolated at the first application. Most safety events were recorded during the learning phase. An oesophageal temperature monitoring is suggested: oesophageal lesions were detected in 8% of patients.

Percutaneous balloon calcaneoplasty versus open reduction and internal fixation (ORIF) for intraarticular SANDERS 2B calcaneal fracture: Comparison of primary stability using a finite element method

INTRODUCTION

Fractures of the calcaneus are common, with 65% being intra-articular, which can lead to a major impairment of the patient's quality of life. Open reduction and internal fixation with locking plates can be considered as gold-standard technique but has a high rate of post-operative complications. Minimally invasive calcaneoplasty combined with minimally invasive screw osteosynthesis is largely drawn from the management of depressed lumbar or tibial plateau fractures. The hypothesis of this study is that calcaneoplasty associated with minimally invasive percutaneous screw osteosynthesis presents biomechanical characteristics comparable with conventional osteosynthesis.

MATERIALS AND METHODS

Eight hind feet were collected. A SANDERS 2B fracture was reproduced on each specimen, while four calcanei were reduced by a balloon calcaneoplasty method and fixed with a lateral screw, four others were manually reduced and fixed with conventional osteosynthesis. Each calcaneus was then segmented for 3D finite element modeling. A vertical load was applied to the joint surface in order to measure the displacement fields and the stress distribution according to the type of osteosynthesis.

RESULTS

Analyses of the intra-articular displacement fields showed lower overall displacements in calcaneal joints treated with calcaneoplasty and lateral screw fixation. Better stress distribution was found in the calcaneoplasty group with lower equivalent joint stresses. These results could be explained by the role of the PMMA cement as a strut, enabling better load transfer.

CONCLUSION

Balloon Calcaneoplasty combined with lateral screw osteosynthesis has biomechanical characteristics at least comparable to locking plate fixation in the treatment of SANDERS 2B calcaneal joint fractures in terms of displacement fields and stress distribution under the premise of anatomical reduction.

'Balloon pressure technique' for endovascular treatment of spinal cord arteriovenous fistulas: preliminary results in 10 cases

BACKGROUND

Spinal arteriovenous fistulas (SAVFs) are challenging lesions to treat by endovascular means. Our purpose was to report our early experience with dual lumen balloons (DLBs) for embolization of SAVFs using ethylene vinyl alcohol (EVOH) (the so-called 'balloon pressure technique' (BPT)).

MATERIALS AND METHODS

During the inclusion period, 10 consecutive patients (nine men, mean age 61.6 years) underwent endovascular treatment of a SAVF (seven dural SAVFs and three epidural SAVFs) at a single institution using the BPT. DLBs were used in all cases. In seven cases (70%), a regular DLB was used, while in three cases (30%), low profile DLBs were used. EVOH was used as the liquid embolic agent in all cases. Technical and clinical complications were systematically recorded. Clinical and angiographic outcomes were systematically evaluated more than 3 months after the procedure.

RESULTS

Complete cure of the SAVF by endovascular means alone was obtained in 80% of cases (8/10). For the two patients with incomplete SAVF occlusion, surgery was successfully performed secondarily. No recurrence was found at the 3 month follow-up in the eight patients for whom complete occlusion was obtained at the end of the embolization procedure. No permanent clinical complication was recorded using the BPT. Clinical improvement was observed in 6/10 (60%) cases.

CONCLUSION

BPT was a feasible technique, with regular or low profile DLBs, for embolization of SAVFs. Our preliminary results suggest the safety and effectiveness of this technique.

The influence of various induction methods on adverse outcomes in small for gestational age neonates: A secondary analysis of the PROBAAT 1 and 2 trials

OBJECTIVE

To evaluate the safety aspects of different induction methods in pregnancies with small-for-gestational-age neonates.

STUDY DESIGN

This was a secondary analysis of two previously reported multicenter, randomized controlled trials conducted in the Netherlands. In the original trials, women were randomized to either a 30 cc Foley catheter, vaginal prostaglandin E2 (PROBAAT-1) or oral misoprostol (PROBAAT-2). A total of 425 patients with a term, singleton pregnancy in cephalic presentation with an indication for labor induction and a small-for-gestational-age neonate were included in this secondary analysis. Our primary outcome was a composed adverse neonatal outcome of Apgar score < 7 after 5 min and/or a pH in the umbilical artery < 7.05 and/or NICU admission. Secondary outcomes were mode of birth, operative birth for fetal distress and pH < 7.10 in the umbilical artery. For these outcome measures, multivariate as well as bivariate analyses were performed.

RESULTS

An adverse neonatal outcome occurred in 4.7 % (10/214) induction with a Foley catheter, versus 12.8 % (19/149) after misoprostol (RR 0.36; 95 % CI 0.17-0.76) and 4.7 % (3/64) after Prostaglandin E2 (RR 0.98; 95 %CI 0.28-3.51). For individual components of the composed outcome of adverse events, a difference was found between a Foley catheter and misoprostol for Apgar score < 7 at 5 min (0.5 % versus 3.4; RR 0.14; 95 %CI 0.02-1.16) and NICU admission (1.9 % versus 6.1 %; RR 0.31; 0.10-0.97). No differences were found for mode of birth.

CONCLUSIONS

For women who gave birth to a small-for-gestational-age neonate, a Foley catheter is probably a safer induction method compared to oral misoprostol.

Infantile dural sinus malformation: curative embolization in two stages with the Scepter mini balloon microcatheter

Endovascular embolization is the mainstay for treatment of infantile dural sinus malformations.1 2 Distal access and flow control are limiting factors in controlled embolization.3-6 The Scepter mini catheter (Microvention, Aliso Viejo, California, USA) is a low-profile, dual-lumen balloon microcatheter designed to provide navigability in small-caliber, tortuous intracranial vessels. In this technical video, we demonstrate the staged embolization of a dural sinus malformation with multiple arteriovenous fistulae using the Scepter mini catheter (video 1). In the newborn patient, embolizations were performed through the parietal branches of the left and right middle meningeal arteries. The catheter easily navigated into the small feeding arteries. No neurological complications occurred due to the procedures. Post-embolization injections demonstrated significant flow reduction into the malformation. Three-month follow-up angiography illustrated resolution of the previously dilated left transverse sinus. Complete obliteration of the dural sinus malformation was achieved in the newborn patient. neurintsurg;15/1/97/V1F1V1Video 1Curative embolization in two stages with the Scepter mini balloon microcatheter. ΑP, anteroposterior; CCA, common carotid artery.

Management of chyluria using percutaneous thoracic duct stenting

BACKGROUND

Thoracic duct stenosis or obstruction is one of the causes of chyluria. Although the diagnosis of chyluria is not difficult, treatment is still challenging. Although there have been no standard guidelines for the treatment of chyluria, interventional techniques now offer minimally invasive treatment options for chyluria such as interstitial lymphatic embolization, ductoplasty with balloon, or thoracic duct stenting. CASE PRESENTATION : Here, we report a case of chyluria due to obstruction of the junction between the thoracic duct and subclavian vein in a 64 -year- old female patient. The patient was treated with balloon plasty for lymphovenous junction obstruction and interstitial lymphatic embolization for chyluria. However, chyluria was recurrent after 6 months so intranodal lymphangiography was performed. Anterograde thoracic duct was accessed through a transabdominal to the cisterna chyli which showed that the thoracic venous junction was re-obstruction. The patient was successfully treated by placing a uncovered drug-eluting stent with the size of 2.5 mm x 15 mm in length for resolving the thoracic occlusion.

CONCLUSION

This report demonstrates the feasibility of using thoracic duct stenting in the treatment chyluria due to lymphovenous junction obstruction.

Safety of Sheathless Transradial Balloon Guide Catheter Placement for Acute Stroke Thrombectomy

BACKGROUND

Transradial access has been described for mechanical thrombectomy in acute stroke, and proximal balloon occlusion has been shown to improve recanalization and outcomes. However, sheathed access requires a larger total catheter diameter at the access site. We aimed to characterize the safety of sheathless transradial balloon guide catheter use in acute stroke intervention.

METHODS

Consecutive patients who underwent sheathless right-sided transradial access for thrombectomy with a balloon guide catheter were identified in a prospectively collected dataset from 2019 to 2021. Demographics, procedure details, and short-term outcomes were collected and reported with descriptive statistics.

RESULTS

A total of 48 patients (20 women) with a mean age of 72.3 years were identified. Of patients, 56.3% had occlusions in the left-sided circulation; 35 (72.9%) had M1 occlusions, 7 (14.6%) had M2 occlusions, and 6 (12.5%) had internal carotid artery occlusions. Tissue plasminogen activator was administered to 16 (33.3%) patients. Five (10.4%) patients underwent intraprocedural carotid stenting. The cohort had successful reperfusion after a median of 1 (interquartile range: 1, 2) pass. Median time from access to recanalization was 31 (interquartile range: 25, 53) minutes. A postprocedural Thrombolysis In Cerebral Infarction score of ≥2b was achieved in 46 (95.8%) patients. Five patients had wrist access site hematomas. All hematomas resolved with warm compresses, and no further intervention was required.

CONCLUSIONS

Sheathless radial access using a balloon guide catheter may be safely performed for acute ischemic stroke with excellent radiographic outcomes. Further investigation is warranted to evaluate the comparative effectiveness of sheathless compared with sheathed transradial balloon guide access.

Dual microcatheter and coil/balloon pressure cooker technique for transvenous embolization of cerebrospinal fluid-venous fistulas

Cerebrospinal fluid-venous fistula is increasingly recognized as a cause of spontaneous intracranial hypotension.1 Transvenous embolization is emerging as an efficacious minimally invasive treatment.2-4 The procedure aims to embolize paraspinal and foraminal veins draining the fistula; however, complete embolization may be challenging as numerous small venous tributaries at the foraminal venous plexus, including dorsal muscular branches, may serve as additional routes of cerebrospinal fluid egress.5 To ensure curative embolization, we adopted a dual microcatheter pressure cooker technique, previously used for treatment of brain arteriovenous malformations.6 This allows improved control of embolic material reflux and greater chance of complete embolization of the site of the fistula and all potential venous tributaries. Video 1 demonstrates this technique employed in a typical case using Onyx (Medtronic, Minnesota, USA) to embolize a cerebrospinal fluid-venous fistula at the left L1 neural foramen.neurintsurg;neurintsurg-2022-019005v1/V1F1V1Video 1Disclaimer: this video summarises a scientific article published by BMJ Publishing Group Limited (BMJ). The content of this video has not been peer-reviewed and does not constitute medical advice. Any opinions expressed are solely those of the contributors. Viewers should be aware that professionals in the field may have different opinions. BMJ does not endorse any opinions expressed or recommendations discussed. Viewers should not use the content of the video as the basis for any medical treatment. BMJ disclaims all liability and responsibility arising from any reliance placed on the content.

Carotid Angioplasty and Stenting for Occlusive Diseases

Stenting for carotid artery stenosis (CAS) was once denied 15 years ago because it failed to prove the non-inferiority to carotid endarterectomy (CEA). However, it is now reevaluated and is thought better due to higher safety and efficacy thanks to the development of devices, strategies, and various protection methods. To achieve the safe CAS, protection methods and stents should be properly selected based on the vessel course and plaque components on the preoperative plaque images. Particularly multiple protection methods including proximal balloon protection and double-layer micromesh stents are useful for the cases with high-risk and fragile plaque. Perioperative anti-platelet management and the control of blood pressure are also important to avoid the ischemic complications and hyperperfusion. Properly protected and tailored CAS based on the risk management has dramatically improved the clinical results and contributed to extend the indication for more difficult lesions.

Editor's Choice - Risk of Major Amputation Following Application of Paclitaxel Coated Balloons in the Lower Limb Arteries: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

OBJECTIVE

There have been concerns about the long term safety of paclitaxel coated devices in the lower limbs. A formal systematic review and meta-analysis of randomised controlled trials (RCTs) was performed to examine the long term risk of major amputation using paclitaxel coated balloons in peripheral arterial disease (PAD).

METHOD

This systematic review was registered with PROSPERO (ID 227761). A broad bibliographic search was performed for RCTs investigating paclitaxel coated balloons in the peripheral arteries (femoropopliteal and infrapopliteal) for treatment of intermittent claudication or critical limb ischaemia (CLI). The literature search was last updated on 20 February 2021 without any restrictions on publication language, date, or status. Major amputations were analysed with time to event methods employing one and two stage models. Sensitivity and subgroup analyses, combinatorial meta-analysis, and a multivariable dose response meta-analysis to examine presence of a biological gradient were also performed.

RESULTS

In all, 21 RCTs with 3 760 lower limbs were analysed (52% intermittent claudication and 48% CLI; median follow up two years). There were 87 major amputations of 2 216 limbs in the paclitaxel arms (4.0% crude risk) compared with 41 major amputations in 1 544 limbs in the control arms (2.7% crude risk). The risk of major amputation was significantly higher for paclitaxel coated balloons with a hazard ratio (HR) of 1.66 (95% CI 1.14 - 2.42; p = .008, one stage stratified Cox model). The prediction interval was 95% CI 1.10 - 2.46 (two stage model). The observed amputation risk was consistent for both femoropopliteal (p = .055) and infrapopliteal (p = .055) vessels. Number needed to harm was 35 for CLI. There was good evidence of a significant non-linear dose response relationship with accelerated risk per cumulative paclitaxel dose (chi square model p = .007). There was no evidence of publication bias (p = .80) and no significant statistical heterogeneity between studies (I2 = 0%, p = .77). Results were stable across sensitivity analyses (different models and subgroups based on anatomy and clinical indication and excluding unpublished trials). There were no influential single trials. Level of certainty in evidence was downrated from high to moderate because of sparse events in some studies.

CONCLUSION

There appears to be heightened risk of major amputation after use of paclitaxel coated balloons in the peripheral arteries. Further investigations are warranted urgently.

Effect of coarctation of aorta anatomy and balloon profile on the outcome of balloon angioplasty in infantile coarctation

OBJECTIVE

Coarctation of the Aorta (CoA) is a relatively common cardiovascular disorder. The present study aimed to evaluate the effect of COA anatomy and high versus low-pressure balloons on the outcome of balloon angioplasty among neonates and infants.

METHODS

In this retrospective study, the neonates and infants undergoing balloon angioplasty at Namazi hospital were enrolled. After balloon angioplasty, immediate data results were promptly recorded.Moreover, midterm echocardiographic information was collected via electronic cardiac records of pediatric wards and clinical and echocardiographic data at least 12 months after balloon angioplasty. Finally, data were analyzed using SPSS-20.

RESULTS

In this study, 42 infants were included. The median age at the time of balloon angioplasty was 1.55 (range 0.1-12) months and 66.7% of the patients were male. The mean pressure gradient of coarctation was 38.49 ± 24.97 mmHg, which decreased to 7.61 ± 8.00 mmHg (P < 0.001). A high-pressure balloon was used in 27, and a low-pressure balloon was used in 15 patients. COA's pressure gradient changed 30.89 ± 18.06 in the high-pressure group and 24.53 ± 20.79 in the low-pressure balloon group (P = 0.282). In the high-pressure balloon group, 14.81% and in the low-pressure group, 33.33% had recoarctation and need second balloon angioplasty (p < 0.021). The infant with discrete coarctation had a higher decrease in gradient and lower recoarctation.

CONCLUSION

Recoarctation rate was lower in the high-pressure balloon. The infant with discrete COA had a better response to the balloon with more decrease in gradient and lower recoarctation rate. Therefore, the stenotic segment anatomy needs to be considered in the selection of treatment methods.

Recoartación de la aorta en pacientes sometidos a angioplastia percutánea con o sin implantación de stent

Objetivo:

La coartación de la aorta puede ser tratada quirúrgicamente o con angioplastia con balón. El objetivo de nuestro estudio fue describir los resultados postangioplastia percutánea con balón con o sin implantación de stent para coartación de la aorta y establecer la incidencia de recoartación en el seguimiento.

Método:

Estudio de cohorte, se incluyeron pacientes de cualquier edad en un periodo de seguimiento de nueve años.

Resultados:

Se incluyeron 89 pacientes, un 69.0% hombres. La media de seguimiento para todos los participantes fue de 33.66 meses. Al 32.5% se les implantó un stent en angioplastia; de los cuales el 24.1% se recoartaron durante el seguimiento. En el grupo sin stent se recoartaron un 36.6%. No hubo diferencia significativa en las curvas de supervivencia de los dos grupos (p = 0.889).

Conclusiones:

La implantación de stent durante la angioplastia con balón para tratar coartación de aorta no influyó en la incidencia de recoartación de la aorta; pero factores como la hipertensión arterial preangioplastia y el gradiente final de angioplastia > 20 mmHg se asoció con recoartación de la aorta.

Clinical and hemodynamic insights into the use of internal iliac artery balloon occlusion as a prophylactic technique for treating postpartum hemorrhage

Recently, the effectiveness of internal iliac artery balloon occlusion (IIABO) for treating postpartum hemorrhage caused by pernicious placenta previa (PPP) has been questioned. We conducted a retrospective analysis and hemodynamic simulation to assess the IIABO's effectiveness. The retrospective analysis involved 480 patients with PPP, among which 288 underwent IIABO treatment and the remaining 192 were used as controls. Blood loss and preoperative indicators were recorded, and multiple regression analysis was applied to test the effect of preoperative indicators on blood loss. Hemorrhage mechanisms were simulated using a numerical model. Results suggested that no significant difference in blood loss (1836 ± 1440 ml vs. 1784 ± 1647 ml, p = 0.22) was observed between the two groups. In addition, preoperative indicators, including age, weight, gestational age, gravidity, parity, blood type, anemia, or diabetes, were not associated with blood loss. In the simulation, after the intra-iliac artery was blocked, blood loss was caused by a reversed flow in the intrapelvic arteries, uterine veins, and uterine venules. The ratio of the time-averaged hemorrhage velocity (TAHV) in the balloon group to that in the control group was lower than that obtained in a clinical study (13.0% vs. 88.9%); in the presence of collateral circulation, blood loss occurred from collateral circulation and uterine venules after IIABO intervention, and the TAHV was 60%-90% that of the control group, which was closer to the clinical results (88.9%). These results suggest that IIABO cannot effectively treat postpartum hemorrhage because of the collateral circulation and reversed flow in the uterine venules.

Balloon-Assisted Roadmap Technique to Enable Flow Diversion of a High-Flow Direct Carotid-Cavernous Fistula

BACKGROUND

The use of flow diverters as a first-line treatment for direct carotid cavernous fistula (CCF) is a relatively new approach in the neurointerventional field which allows obliteration of the fistula with less mass effect from coils in the cavernous sinus. Safe and successful deployment of a flow diverter requires adequate imaging of the parent vessel, which may be challenging in the setting of high-flow CCF without antegrade flow.

OBJECTIVE

To facilitate adequate parent vessel imaging in the setting of high-flow CCF to enable the safe development of a flow diverter device.

METHODS

Here we present the case of a patient with delayed presentation of post-traumatic direct CCF after a motor vehicle accident, with no antegrade flow past the fistulous connection. We used temporary balloon occlusion of the fistulous connection to enable road-map imaging of the parent vessel and flow-diverter placement. "Drag and drop" device opening in the middle cerebral artery facilitated better deployment of the flow-diverter against retrograde cavernous flow through the fistula.

RESULTS

Temporary balloon occlusion of the fistulous connection was used to acquire a roadmap to facilitate safe deployment of a flow diverter and subsequent treatment of the CCF with transvenous coil embolization, with complete resolution of symptoms.

CONCLUSION

Balloon-assisted roadmap use is a novel means of visualizing the parent vessel in direct CCF to facilitate safe flow diverter deployment.

Cervical ripening for a singleton fetus in breech prensentation at term: Comparison between mechanical and pharmaceutical methods

Although various international professional societies currently recommend trial of vaginal delivery of term fetuses in breech presentation, the question of the method of cervical ripening, when necessary, remains open.

OBJECTIVE

To compare the effectiveness of two methods of cervical ripening for delivery of a singleton fetus in breech presentation at term: a mechanical method (balloon catheter) and a pharmaceutical method (prostaglandins).

STUDY DESIGN

This two-center retrospective study reviewed records from 2014 through 2019 in two French maternity units with two different cervical ripening methods for fetuses in breech presentation. The study included all women with cervical ripening for a medical indication with a live singleton fetus in breech presentation ≥ 37 weeks, with an unfavorable cervix. The group treated with a mechanical method was compared with the group receiving a pharmaceutical method. The cesarean delivery rate was the principal outcome, and maternal and neonatal morbidity the secondary outcomes.

RESULTS

We included 74 women, 19 with mechanical cervical ripening, and 55 with pharmaceutical treatment. The cesarean rate was 57.9% in the balloon catheter group and 40% in the prostaglandin group (P = 0.097) (crude OR =2.06, 95% CI [0.72 - 5.94]; adjusted OR = 2.88, 95% confidence interval [0.52-15.96]), and the postpartum hemorrhage rates 21.1% and 1.8% respectively (P = 0.008). Neonatal morbidity did not differ significantly.

CONCLUSION

Although the cesarean rate and neonatal morbidity and mortality did not differ significantly between these two methods of cervical ripening, our study lacked power.

Excimer laser atherectomy combined with drug-coated balloon versus drug-eluting balloon angioplasty for the treatment of infrapopliteal arterial revascularization in ischemic diabetic foot: 24-month outcomes

There are few studies on excimer laser (308 nm) atherectomy in the treatment of infrapopliteal artery disease. The purpose of this retrospective clinical study was to assess the efficacy and safety of excimer laser atherectomy (ELA) in combination with adjuvant drug-coated balloon angioplasty (DCB) compared to DCB for infrapopliteal arterial revascularization in patients with ischemic diabetic foot. From September 2018 to February 2019, a total of 79 patients with diabetic foot were treated for infrapopliteal arterial revascularization at Tianjin First Central Hospital (Tianjin, China). In this project, 35 patients were treated with ELA combined with DCB angioplasty, and 44 patients were treated with DCB angioplasty. The patients' baseline characteristics were similar between the 2 groups. The primary efficacy endpoints through 24 months were clinically driven target lesion revascularization (CD-TLR), wound healing rate, major amputation rate, and target vessel patency rate. The primary safety endpoint through 24 months was all-cause mortality. The primary efficacy results at 24 months of ELA + DCB versus DCB were CD-TLR of 14.3% versus 34.1% (p = 0.044), wound healing rate of 88.6% versus 65.9% (p = 0.019), target vessel patency rate of 80.0% versus 52.3% (p = 0.010), and major amputations rate of 5.7% versus 22.7% (p = 0.036). The safety signal at 24 months of all-cause mortality rate was 2.9% for ELA + DCB group and 4.5% for DCB group (p = 0.957). ELA combined with DCB angioplasty is more effective than DCB in the treatment of infrapopliteal artery disease in patients with ischemic diabetic foot, which can improve the wound healing rate and target vessel patency rate. There was no statistical difference in the safety results between the two groups.

Technique to "Trap" a Segment of the Middle Meningeal Artery for Embolization of a Carotid Cavernous Fistula: 2-Dimensional Operative Video

Transvenous embolization is the favored treatment for indirect carotid-cavernous fistulas (CCFs). However, transarterial embolization can be used as an alternative method when the venous route is inaccessible. We present the case of a 47-yr-old woman with a history of diplopia, headaches, and sixth cranial nerve (CN-VI) palsy who presented with acute worsening of headache and ophthalmoplegia and rise of intraocular pressures. Angiography demonstrated a left indirect CCF (dural arteriovenous malformation) with multiple arterial feeders from the internal carotid artery as well as the middle meningeal artery (MMA) (Barrow type D). Transvenous approach was attempted first but was unsuccessful due to difficult access to the cavernous sinus. Thus, transarterial embolization through the MMA feeding branches was planned. To avoid occluding distal branches of the MMA by Onyx, we coiled it distally. In addition, we used a scepter balloon proximally to prevent the reflux of Onyx into potential collaterals to cranial nerves from proximal MMA. After trapping a segment of the MMA, Onyx was injected into the CCF fistula through the small MMA feeders. A postembolization arteriogram showed obliteration of the CCF. The patient developed mild left facial nerve paresis on the first postoperative day (thought to be related to partial embolization of tiny arteries in the facial canal), which was resolving in the course of hospitalization. She remained neurologically stable, and was discharged on the third postoperative day. To the best of our knowledge, this is the first report of transarterial embolization of CCF by distal coiling and proximal ballooning to trap a segment of an artery. The authors hereby confirm that informed consent was obtained from the patient after thorough discussion of the procedure's rationale, risks, benefits, and alternatives.

Novel side by side Foley catheter balloons for 'extended labour induction': Concept, simulation study and clinical application

OBJECTIVE

To introduce the concept of extended or prolonged mechanical balloon labour induction as opposed to pharmacological methods and amniotomy after single balloon expulsion, by the novel use of side-by-side Foley catheter balloons. This method is of particular relevance when there is prior uterine surgery, fetal reserve is uncertain, the risk of vertical infection is high, or facilities for labour monitoring are limited.

STUDY DESIGN

We conducted simulation studies to compare balloon circumferences and resistance to passage through a simulation cervix between different gauge, fluid distension volume and number of Foley catheters. We describe an illustrative clinical case.

RESULTS

In simulation studies we found modest increases in Foley catheter balloon circumference with increased catheter gauge and with increasing volume of distending fluid. We found that retention of Foley balloon(s) by a flexible simulated cervix was increased with the gauge, distending volume and number of balloons used side-by-side. We describe the case of a mother with pre-eclampsia with severe features and compromised fetal reserve in whom the side-by-side balloon method achieved spontaneous delivery after a single balloon had been expelled without labour commencing.

CONCLUSIONS

Institutional protocols for Balloon labour inductions should take into account the characteristics of locally-available balloon catheters. Further research is justified to determine the usefulness of extended mechanical labour induction with side-by-side balloon catheters, particularly with prior caesarean section, uncertain fetal reserve and settings with limited fetal monitoring capacity.

Numerical Analysis for Non-Uniformity of Balloon-Expandable Stent Deployment Driven by Dogboning and Foreshortening

PURPOSE

Stenting is the most common intervention for arteriosclerosis treatment; however, the success of the treatment depends on the incidence of in-stent restenosis (ISR). Stent deployment characteristics are major influencers of ISR and can be measured in terms of dogboning, asymmetry, and foreshortening. This study aimed to analyse the implications of balloon and stent-catheter assembly parameters on the stent deployment characteristics.

METHODS

Experimental approach to analyse the impact of the balloon and stent-catheter assembly parameters on stent deployment characteristics is a time-consuming and complex task, whereas numerical methods prove to be quick, efficient, and reliable. In this study, eleven finite element models were employed to analyse non-uniform balloon stent expansion pattern, comprised of variation in, stent axial position on balloon, balloon length, balloon folding pattern, and balloon wall thickness.

RESULTS

Obtained results suggest that the axially noncentral position of the stent on balloon and variable balloon thickness lead to non-uniform stent deployment pattern. Also, it was proved that variation in balloon length and balloon folding pattern influence deployment process.

CONCLUSION

Improved positional accuracies, uniform balloon wall thickness, and selection of the appropriate length of a balloon for selected stent configuration will help to minimize dogboning, asymmetry, and foreshortening during non-uniform stent expansion, thereby reducing the risk of restenosis. The stated numerical approach will be helpful to optimize stent catheter assembly parameters thus minimizing in-vitro tests and product development time.