The Impact of Conscious Sedation versus General Anesthesia for Stroke Thrombectomy on the Predictive Value of Collateral Status: A Post Hoc Analysis of the SIESTA Trial

BACKGROUND AND PURPOSE:Radiologic selection criteria to identify patients likely to benefit from endovascular stroke treatment are still controversial. In this post hoc analysis of the recent randomized Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial, we aimed to investigate the impact of sedation mode (conscious sedation versus general anesthesia) on the predictive value of collateral status.MATERIALS AND METHODS:Using imaging data from SIESTA, we assessed collateral status with the collateral score of Tan et al and graded it from absent to good collaterals (0–3). We examined the association of collateral status with 24-hour improvement of the NIHSS score, infarct volume, and mRS at 3 months according to the sedation regimen.RESULTS:In a cohort of 104 patients, the NIHSS score improved significantly in patients with moderate or good collaterals (2–3) compared with patients with no or poor collaterals (0–1) (P = .011; mean, −5.8 ± 7.6 versus −1.1 ± 10.7). Tan 2–3 was also associated with significantly higher ASPECTS before endovascular stroke treatment (median, 9 versus 7; P < .001) and smaller mean infarct size after endovascular stroke treatment (median, 35.0 versus 107.4; P < .001). When we differentiated the population according to collateral status (0.1 versus 2.3), the sedation modes conscious sedation and general anesthesia were not associated with significant differences in the predictive value of collateral status regarding infarction size or functional outcome.CONCLUSIONS:The sedation mode, conscious sedation or general anesthesia, did not influence the predictive value of collaterals in patients with large-vessel occlusion anterior circulation stroke undergoing thrombectomy in the SIESTA trial.

Endovascular stroke treatment (EST) is now the first choice for acute ischemic stroke in the anterior circulation caused by large-vessel occlusion.^1,2 However, selection criteria to identify patients likely to benefit from EST outside highly selective randomized trials (RCTs) are still controversial. It is also important to establish practicable selection criteria for thrombectomy failure to exclude patients prone to futility and save financial, facility, and personnel resources and, above all, avoid complications like cerebral reperfusion injuries.Current data suggest that collateral blood flow status is a strong independent predictor of therapeutic success and functional outcome after EST.^3–5 By a network of pre-existing anastomoses, compensatory cerebral collateral blood flow supplies oxygen-deprived brain areas to which the primary flow path is blocked due to large-vessel occlusion. The recently published post hoc analysis on the collateralization status from the seminal thrombectomy trial MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands) showed the highest interventional therapeutic effect in patients with moderate-to-good collateral blood flow.⁶Why should the chosen sedation/airway regimen influence the impact of collateralization during EST? Collateral effects depend on cerebral perfusion pressure and vasomotor regulation of the vessel diameter. On the one hand, intubation and general anesthesia (GA) are often associated with a substantial drop in blood pressure⁷ as was shown in previous EST studies.^8–10 It is quite likely that hypotension may compromise even patients with a good collateral status, particularly if their cerebral autoregulation is impaired as is often the case in severe acute ischemic stroke. Moreover, inadvertent mechanical hyperventilation and subsequent hypocarbia can lead to cerebral vasoconstriction.^8,11 Both hypotension and hypocarbia associated with GA may have disadvantageous effects on the insufficiently supplied penumbra. Indeed, many retrospective studies have suggested worse outcome and mortality associated with GA in EST.¹² On the other hand, steering GA in ways that stabilize circulation and aim for normocarbia may theoretically serve to improve collateralization.We recently conducted the Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) study to compare GA with conscious sedation (CS) during EST.¹³ In that first RCT on peri-interventional management, strict target values for physiologic parameters, including blood pressure and CO₂, were predefined for both treatment groups, mainly to avoid hypocarbia and hypotension. SIESTA showed no difference between GA and CS with regard to early neurologic improvement measured by the NIHSS after 24 hours,¹⁴ and unadjusted long-term outcome was even better in patients in the GA group. Of note, SIESTA was not powered and designed to primarily investigate long-term functional outcome, and slight imbalances in reperfusion grades, for example, may still have influenced that result even though the results were not statistically significant. This result was in strong contrast to most previous, yet retrospective, studies on the subject.Why was GA not inferior in SIESTA? We hypothesized that the protocolized way GA was conducted may not have compromised or even improved collateralization. In this post hoc analysis of imaging data from the SIESTA study, we mainly aimed to investigate whether the predictive value of collateral status for infarct volume and outcome is affected by the applied sedation mode (CS versus GA) and, more specifically, whether patients under a very standardized GA may have shown a favorable course despite a suboptimal collateral status at baseline.     

Conscious Sedation versus General Anesthesia during Endovascular Acute Ischemic Stroke Treatment: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE:A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types.MATERIALS AND METHODS:In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization.RESULTS:Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87–3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36–3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35–0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37–0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score.CONCLUSIONS:Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association.

Intra-arterial recanalization for acute ischemic stroke is commonly used in patients with large-vessel occlusion.¹ Timely recanalization of the occluded vessel with either IV-tPA or intra-arterial therapy is essential in preventing neuronal death and improving patient outcome.² A number of factors affect patient outcomes following endovascular recanalization, possibly including choice of anesthetic agent during the procedure. Moderate conscious sedation and general anesthesia with intubation are the 2 most commonly used anesthesia techniques for patients with acute ischemic stroke undergoing endovascular recanalization.³ General anesthesia is often the preferred method due to the perceptions of improved procedural safety and efficacy.³ However, conscious sedation and local anesthesia allow operators to monitor neurologic status during the procedure and avoid delays in procedure initiation.⁴ Furthermore, conscious sedation may be associated with improved hemodynamic stability compared with general anesthesia. Due to the continuing debate regarding anesthesia choices during intra-arterial treatment of acute ischemic stroke, we performed a meta-analysis of studies comparing outcomes of patients with stroke receiving general anesthesia and conscious sedation during the procedures.^5,6     

Sex-Related Differences in the Long-Term Outcomes of Patients with Femoropopliteal Arterial Disease Treated with the IN.PACT Drug-Coated Balloon in the IN.PACT SFA Randomized Controlled Trial: A Post Hoc Analysis

PurposeTo evaluate sex-related disparities in long-term outcomes of patients with peripheral artery disease (PAD) treated with IN.PACT drug-coated balloon (DCB) or percutaneous transluminal angioplasty (PTA).Materials and MethodsA post hoc analysis of the IN.PACT SFA trial was performed. Participants with Rutherford Clinical Classification 2–4 PAD and femoropopliteal artery lesions up to 18 cm long were randomly assigned to treatment with DCB (n = 220) or PTA (n = 111). Effectiveness outcomes were evaluated, including 36-month primary patency (freedom from binary restenosis and freedom from clinically driven [CD] target lesion revascularization [TLR]).ResultsIn the DCB group, women were significantly older (69.4 y ± 9.9) than men (66.4 y ± 9.1; P = .025). Mean reference vessel diameter (RVD) was significantly smaller in women (4.4 mm ± 0.68) compared with men (4.8 mm ± 0.89, P < .001). Primary patency was 65.4% in women and 71.8% in men (P = .302). Freedom from CD-TLR was 81.1% in women and 86.4% in men (P = .285). Women treated with PTA were older (70.4 y ± 8.3) than men (66.9 y ± 9.5; P = .063). Mean RVD was significantly smaller in women (4.2 mm ± 0.77) compared with men (4.9 mm ± 0.77, P < .001). Primary patency was 42.3% in women and 46.7% in men (P = .551). Freedom from CD-TLR was 59.4% in women and 75.5% in men (P = .109). No significant differences were noted in safety and mortality outcomes.ConclusionsIn both groups, women were older and had smaller vessels. Particularly in the PTA group, women had worse clinical outcomes, though not reaching statistical significance. Further evaluation is necessary to understand the disparate nature of disease progression and outcomes following endovascular treatment in women compared with men.     

全麻时监测临床病人神经活动状态的新方法

目的 探讨全麻时神经活动的状态,寻找对全麻时神经活动状态进行检测的新方法.方法 随机采集了临床外科全麻胸腹手术中18位病人的双通道(FP1-Cz, FP2-Cz)脑电数据,通过分析EEG 的Kolmogorov熵的变化趋势,进而判断全麻时病人神经活动的状态.结果 同一种麻醉措施作用下,大部分病人神经活动的状态是相同的,但也存在个体差异:同一种麻醉措施,有些病人大脑皮层前额叶区域的中枢神经系统呈现抑制状态,有些则呈现兴奋状态,还有些呈现癫痫状态.结论 同一种麻醉药品对不同被试者其作用会有差别;通过分析全麻状态下脑电信号Kolmogorov熵的变化能够有效检测中枢神经活动的状态;Kolmogorov熵能成为临床麻醉监测的一种新工具.     

Mechanical Thrombectomy for Isolated M2 Occlusions: A Post Hoc Analysis of the STAR,SWIFT, and SWIFT PRIME Studies

BACKGROUND AND PURPOSE:Mechanical thrombectomy is beneficial for patients with acute ischemic stroke and a proximal anterior occlusion, but it is unclear if these results can be extrapolated to patients with an M2 occlusion. The purpose of this study was to examine the technical aspects, safety, and outcomes of mechanical thrombectomy with a stent retriever in patients with an isolated M2 occlusion who were included in 3 large multicenter prospective studies.MATERIALS AND METHODS:We included patients from the Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), Solitaire With the Intention For Thrombectomy (SWIFT), and Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) studies, 3 large multicenter prospective studies on thrombectomy for ischemic stroke. We compared outcomes and technical details of patients with an M2 with those with an M1 occlusion. All patients were treated with a stent retriever. Imaging data and outcomes were scored by an independent core laboratory. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score of 2b/3.RESULTS:We included 50 patients with an M2 and 249 patients with an M1 occlusion. Patients with an M2 occlusion were older (mean age, 71 versus 67 years; P = .04) and had a lower NIHSS score (median, 13 versus 17; P < .001) compared with those with an M1 occlusion. Procedural time was nonsignificantly shorter in patients with an M2 occlusion (median, 29 versus 35 minutes; P = .41). The average number of passes with a stent retriever was also nonsignificantly lower in patients with an M2 occlusion (mean, 1.4 versus 1.7; P = .07). There were no significant differences in successful reperfusion (85% versus 82%, P = .82), symptomatic intracerebral hemorrhages (2% versus 2%, P = 1.0), device-related serious adverse events (6% versus 4%, P = .46), or modified Rankin Scale score 0–2 at follow-up (60% versus 56%, P = .64).CONCLUSIONS:Endovascular reperfusion therapy appears to be feasible in selected patients with ischemic stroke and an M2 occlusion.

Recent data have shown that mechanical thrombectomy (MT) with a stent retriever is safe and improves functional outcome in patients with acute ischemic stroke and an occlusion of the anterior circulation.^1–5 It is unclear, however, if these results can be extrapolated to patients with an occlusion of the second segment of the middle cerebral artery (M2 occlusion). Because of its distal location, smaller diameter, and thinner walls, MT of the M2 segment is technically more challenging and may be associated with a higher risk of periprocedural complications. The potential benefit of reperfusion may also be different, in part because M2 occlusions generally respond better to IV thrombolysis.⁶The number of patients with an M2 occlusion in the thrombectomy trials was small. The Multicenter Randomized Clinical trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) protocol did allow recruitment of these patients, but <8% of included patients had an isolated M2 occlusion.¹ In the Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT), Endovascular Treatment for Small Core Proximal Occlusion Ischemic Stroke (ESCAPE), and Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial (EXTEND-IA), only 10, 6, and 4 patients with an isolated M2 occlusion were treated with MT, respectively.^2,4,5 The Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) protocol excluded M2 occlusions, but there were some protocol violations.³ Thus far, none of these studies has specifically examined the subgroup of M2 occlusions. The aim of our study was to examine the technical aspects, safety, and outcomes of MT with a stent retriever in patients with an isolated M2 occlusion who were included in 3 large multicenter prospective studies.     

踝部神经阻滞麻醉在糖尿病足清创过程中的麻醉效果分析

目的观察踝部神经阻滞麻醉在糖尿病足清创过程中的麻醉效果,探讨其临床应用价值。方法对2017年1月—2017年12月庄河市中心医院内分泌科及大连医科大学附属第二医院创面修复科收治的58例需手术清创治疗的糖尿病足患者于清创前予以踝部神经阻滞麻醉,并在清创过程中观察其麻醉效果。结果 58例患者均麻醉成功,清创过程中均无明显疼痛及不良反应发生。结论踝部神经阻滞麻醉在糖尿病足清创过程中的麻醉效果良好,且操作简便,安全可靠,值得临床推广应用。     

大面积特重度烧伤“干”转“湿”治疗效果分析

目的 总结分析大面积特重度烧伤“干”转“湿”治疗的关键节点及技术要领。方法 对2012年1月至2018年12月来自中国、埃及、印尼、菲律宾的5家医疗中心的37例早期行干燥疗法治疗的大面积特重度烧伤患者改用烧伤创疡再生医疗技术治疗,观察治疗效果。结果 37例患者中,除1例伴有严重多发复合伤患者于治疗第25天死于肺部耐药菌感染外,其余36例患者均顺利完成“干”转“湿”治疗,创面于治疗第17～76 d[（39.5±11.2）d]愈合,住院费用为（13.52±6.30）万元。结论 早期行干燥疗法治疗的大面积特重度烧伤患者改用烧伤创疡再生医疗技术治疗,能够实现“干”转“湿”的治疗目的,且疗效显著,安全可靠,值得临床借鉴。     

Endovascular Treatment of Intracranial Aneurysms with the WEB Device: A Systematic Review of Clinical Outcomes

BACKGROUND AND PURPOSE:Despite the improvement in technology, endovascular treatment of bifurcation intracranial wide-neck aneurysms remains challenging, mainly due to the difficulty of maintaining coils within the aneurysm sac without compromising the patency of bifurcation arteries. The Woven EndoBridge (WEB) device is a recent intrasaccular braided device specifically dedicated to treating such aneurysms with a wide neck by disrupting the flow in the aneurysmal neck and promoting progressive aneurysmal thrombosis.MATERIALS AND METHODS:Using several health data bases, we conducted a systematic review of all published studies of WEB endovascular treatment in intracranial aneurysms from 2010 onward to evaluate its efficacy and safety profile.RESULTS:The literature search identified 6 relevant studies (7 articles) including wide-neck bifurcation aneurysms in ≥80% of cases. Clinical data supporting the efficacy and safety of the WEB are limited to noncomparative cohort studies with large heterogeneity from a methodologic standpoint. The WEB deployment was feasible with a success rate of 93%–100%. Permanent morbidity (mRS of >1 at last follow-up) and mortality were measured at 2.2%–6.7% and 0%–17%, respectively. The adequate occlusion rate (total occlusion or neck remnant) varied between 65% and 85.4% at midterm follow-up (range, 3.3–27.4 months).CONCLUSIONS:Endovascular treatment of bifurcation wide-neck aneurysms with the WEB device is feasible and allows an acceptably adequate aneurysm occlusion rate; however, the rate of neck remnants is not negligible. The WEB device needs further clinical and anatomic evaluation with long-term prospective studies, especially of the risk of WEB compression. Prospective controlled studies should be encouraged.

With the emergence of detachable coils and results of the International Subarachnoid Aneurysm Trial and Barrow Ruptured Aneurysm Trial,^1,2 endovascular coiling has become the first-line option for ruptured intracranial aneurysms. It is also a widely accepted option for unruptured aneurysms that are anatomically suitable for endovascular approaches.³ However, coiling of large and wide-neck intracranial aneurysms is associated with low initial complete obliteration, a high incidence of recanalization (up to 20% at 12 months), and a 10% rate of retreatment.⁴ Promising technologies like flow-diverter stents have the potential to overcome some of the limitations of standard coiling for sidewall aneurysms,^5–7 but the management of large wide-neck bifurcation aneurysms remains challenging. Balloon and stent-assisted techniques have widened the indications for endovascular treatment of aneurysms with a wide neck and/or unfavorable anatomy that were otherwise unsuitable for coiling.^8–10 However, endovascular treatment of such complex intracranial aneurysms requires the use of complex endovascular techniques with double-stent placement in Y and X configurations. Bartolini et al¹¹ suggested that Y and X stent-assisted coiling was associated with a high rate of complications, 10% procedure-related permanent morbidity, and 1% mortality rate.In this context, a new endovascular device, the intrasaccular flow disruptor Woven EndoBridge (WEB; Sequent Medical, Aliso Viejo, California), specifically designed to treat wide-neck bifurcation intracranial aneurysms, has emerged in the past 5 years.^12–14 There is an emerging body of literature on the use of the WEB device, but to our knowledge, no study has specifically reviewed the evidence on its use. We, therefore, performed a literature review of this technique in the management of wide-neck bifurcation intracranial aneurysms. Our specific aims were to evaluate its feasibility, safety, and effectiveness to finally discuss its place in the endovascular treatment of bifurcation intracranial aneurysms.     

Value of CT-Guided Percutaneous Irreversible Electroporation Added to FOLFIRINOX Chemotherapy in Locally Advanced Pancreatic Cancer: A Post Hoc Comparison

PurposeTo compare survival after CT-guided percutaneous irreversible electroporation (IRE) and folinic acid, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) chemotherapy versus FOLFIRINOX only in patients with locally advanced pancreatic cancer (LAPC).Materials and MethodsA post hoc comparison was performed of data derived from a prospective IRE-FOLFIRINOX cohort and a retrospective FOLFIRINOX-only cohort. All patients received a minimum of 3 cycles of FOLFIRINOX for LAPC and were considered eligible for CT-guided percutaneous IRE. Endpoints included overall survival (OS), local and distant progression-free survival, and time to progression (TTP) and were compared using stratified Kaplan-Meier analysis. Patients who received > 8 cycles of FOLFIRINOX before IRE and who had tumors > 6 cm in the FOLFIRINOX-only group were excluded.ResultsOf 103 patients with a diagnosis of LAPC, 52 were deemed eligible (n = 30 IRE-FOLFIRINOX and n = 22 FOLFIRINOX-only). Patients in the FOLFIRINOX-only arm had larger tumors (53 mm ± 19 vs 38 mm ± 7, P = .340), had more locoregional lymph node metastases (23% vs 7%, P = .622), and more often received radiotherapy (7 patients vs 2 patients, P = .027); all other baseline characteristics were comparable. Median OS was 17.0 months (range, 5–35 mo; SD = 6) for IRE-FOLFIRINOX versus 12.4 months (range, 3–22 mo; SD = 6) for FOLFIRINOX-only (P = .038). After sensitivity analyses, median OS was 17.2 months (range, 6–27 mo; SD = 6) versus 12.4 months (range, 7–32 mo; SD = 10) (P = .05). Median TTP was longer in the IRE-FOLFIRINOX group: 14.2 months (range, 5–25 mo; SD = 4) versus 5.2 months (range, 2–22; SD = 6) (P = .0001).ConclusionsIn patients with LAPC after FOLFIRINOX chemotherapy, CT-guided percutaneous IRE may improve OS and TTP. This study may facilitate the design of randomized controlled trials to compare survival after IRE-FOLRINOX versus FOLFIRINOX-only.     

Preoperative Coil Embolization of Side Branches and Postoperative Antifibrinolytic Therapy in Endovascular Aneurysm Repair: A Propensity Score Analysis

Purpose

To demonstrate feasibility and efficacy of preoperative coil embolization of side branches and postoperative tranexamic acid (TXA) therapy for management of type II endoleak and aneurysmal sac regression after endovascular aortic repair (EVAR).

Complications in Stent-Assisted Endovascular Therapy of Ruptured Intracranial Aneurysms and Relevance to Antiplatelet Administration: A Systematic Review

BACKGROUND AND PURPOSE:Despite the increasing use of stent-assisted coiling for ruptured intracranial aneurysms, there is little consensus regarding the appropriate antiplatelet administration for this. The objectives of this systematic review were to provide an overview of complications and their association with the method of antiplatelet administration in stent-assisted coiling for ruptured intracranial aneurysms.MATERIALS AND METHODS:A comprehensive search of the literature in the data bases was conducted to identify studies reporting complications of stent-assisted coiling for ruptured intracranial aneurysms. The pooled event rate of preprocedural thromboembolisms, hemorrhages, and mortality was estimated from the selected studies. Subgroup analyses were performed by the method of antiplatelet administration (pre-, postprocedural, and modified). Meta-analysis was conducted to compare periprocedural complications and mortality between ruptured intracranial aneurysms and unruptured intracranial aneurysms.RESULTS:Of the 8476 studies identified, 33 with 1090 patients were included. The event rates of thromboembolism and intra- and postprocedural hemorrhage were 11.2% (95% CI, 9.2%–13.6%), 5.4% (95% CI, 4.1%–7.2%), and 3.6% (95% CI, 2.6%–5.1%), respectively. Subgroup analyses of thromboembolism showed a statistically significant difference between groups (P < .05). In the preprocedural and modified antiplatelet groups, the risk for thromboembolism in stent-assisted coiling for ruptured intracranial aneurysm was not significantly different from that for unruptured intracranial aneurysm, though this risk of the postprocedural antiplatelet group was significantly higher in ruptured intracranial aneurysms than in unruptured intracranial aneurysms.CONCLUSIONS:On the basis of current evidence, complications of stent-assisted coiling for ruptured intracranial aneurysm may be affected by the method of antiplatelet administration.

Aneurysmal neck remodeling with stents has recently emerged as an effective treatment option. This method is beneficial for treating aneurysms with wide necks or for situations in which coils unexpectedly herniate into the parent vessel, requiring rescue with a device that can reconstrain the coil within the lesion.¹ Currently, various stents specialized for aneurysmal neck remodeling are used during endovascular treatment of intracranial aneurysms. However, physicians are often reluctant to apply stents to acutely ruptured aneurysms due to the necessity of antiplatelet medications. During implantation of stents within an intracranial artery, antiplatelet agents should be administrated and maintained postoperatively to prevent in-stent thrombosis and subsequent ischemic events.² In the setting of acutely ruptured aneurysms, antiplatelet medications may lead to complications such as intraprocedural rebleeding, the need for a ventriculostomy, co-occurrence of an intraparenchymal hematoma, and a high likelihood of future invasive procedures.^3–7Despite the chance of complications, administration of antiplatelet agents is an important element of management when using an intracranial stent, regardless of the presence of an acute aneurysm rupture. The type and/or method of antiplatelet agent might affect the periprocedural complication rate of endovascular aneurysm treatment.^8,9 Despite many previous studies of stent-assisted aneurysm management, no published recommendations or large randomized clinical trials provide a consensus as to the appropriate method of antiplatelet medication in stent-assisted endovascular treatment for ruptured intracranial aneurysms (RIAs). The medication method usually varied depending on the institution or the rationales of clinicians in most published case series. Some review articles suggested a higher risk of complications in endovascular therapy for acutely ruptured aneurysms.^3,10,11 However, these reviews did not analyze independent factors affecting the risk of complications in stent-assisted coiling for RIA, including the application of antiplatelet agents.The purposes of this systematic review were to calculate the accumulated complication risk during stent-assisted coiling for RIA and to assess whether the risk of complications would be affected by the method of antiplatelet administration. This information will guide selection of safer antiplatelet administration for stent-assisted coiling of RIA.     

Analysis of Preoperative Portal Vein Embolization Outcomes in Patients with Hepatocellular Carcinoma: A Single-Center Experience

Purpose

To analyze outcomes of patients with hepatocellular carcinoma (HCC) undergoing preoperative portal vein embolization (PVE).

Clinical and Procedural Outcomes with or without Balloon Guide Catheters during Endovascular Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-analysis with First-line Technique Subgroup Analysis

BACKGROUND:Balloon guide catheters are increasingly used to improve clot retrieval by temporarily stopping proximal blood flow during endovascular thrombectomy.PURPOSE:Our aim was to provide a summary of the literature comparing the procedural and clinical outcomes of endovascular thrombectomy with or without balloon guide catheters, depending on the first-line technique used.DATA SOURCES:We used PubMed/MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews.STUDY SELECTION:We chose studies that compared using balloon guide catheters with not using them.DATA ANALYSIS:Random effects meta-analysis was performed to compare the procedural outcomes measured as the first-pass effect, successful reperfusion, number of passes, procedural duration, arterial puncture to reperfusion time, distal emboli, and clinical outcomes.DATA SYNTHESIS:Overall, a meta-analysis of 16 studies (5507 patients, 50.8% treated with balloon guide catheters and 49.2% without them) shows that the use of balloon guide catheters increases the odds of achieving a first-pass effect (OR = 1.92; 95% CI, 1.34–2.76; P < .001), successful reperfusion (OR = 1.85; 95% CI, 1.42–2.40; P < .001), and good functional outcome (OR =1.48; 95% CI, 1.27–1.73; P < .001). Balloon guide catheters reduce the number of passes (mean difference = −0.35; 95% CI, −0.65 to −0.04; P = .02), procedural time (mean difference = −19.73; 95% CI, −34.63 to −4.83; P = .009), incidence of distal or new territory emboli (OR = 0.5; 95% CI, 0.26–0.98; P = .04), and mortality (OR = 0.72; 95% CI, 0.62–0.85; P < .001). Similar benefits of balloon guide catheters are observed when the first-line technique was a stent retriever or contact aspiration, but not for a combined approach.LIMITATIONS:The analysis was based on nonrandomized trials with a moderate risk of bias.CONCLUSIONS:Current literature suggests improved clinical and procedural outcomes associated with the use of balloon guide catheters during endovascular thrombectomy, especially when using the first-line stent retriever.

Acute stroke management changed drastically after 2015, when endovascular thrombectomy became the standard-of-care treatment for large-vessel occlusion.^1-3 Shorter procedural time and successful recanalization were the independent procedural predictors of favorable clinical outcome after endovascular thrombectomy.^4-6 Currently, there is no consensus on the optimal procedural techniques or devices to achieve fast and complete endovascular reperfusion. Stand-alone strategies of stent retriever and contact aspiration have emerged as the most popular approaches for endovascular thrombectomy⁷ without definite differences in clinical and procedural outcomes.^8-12 Combined techniques of stent retriever and contact aspiration have also been shown to result in high rates of successful reperfusion and good functional outcomes and are now increasingly used. ^13,14During endovascular thrombectomy, using a balloon guide catheter has been associated with higher recanalization rates and better functional outcomes in early clinical studies. ^15,16 Balloon guide catheters offer transient proximal flow arrest and decrease the forward pressure impacting the clot, which has been shown to prevent distal thrombus migration or embolization to new vascular territories during retrieval.^17,18 Despite level 2A evidence suggesting benefits of stent retrievers in conjunction with proximal balloon guide catheters,² there is continued debate over their use in everyday clinical practice, especially when used in conjunction with contact aspiration.Two previous meta-analyses suggested that the use of balloon guide catheters during endovascular thrombectomy is associated with improved clinical and angiographic outcomes.^19,20 However, a few larger registries have since been published in addition to many endovascular thrombectomy procedural modifications. Thus, we conducted this updated systematic review to investigate the effects of balloon guide catheters on the clinical and procedural outcomes following endovascular thrombectomy and considering the first-line endovascular thrombectomy technique: stent retriever, contact aspiration, or a combination (stent retriever + contact aspiration).     

恶性骨肿瘤超声聚焦刀与介入联合治疗后影像学检查的初步研究

目的 探讨恶性骨肿瘤行高强度聚焦超声（ＨＩＦＵ）联合肿瘤供血动脉内灌注化疗和全身化疗的临床和影像学特征。材料与方法 ４３例恶性骨肿瘤患者接受ＨＩＦＵ、介入和全身化疗的联合治疗,观察临床及影像学变化,重点是肿瘤血管造遥好转、变化情况。结果 联合治疗后绝大部分患者临床指标明显改善,保肢率为９５％（４１／４３）。Ｘ线、ＣＴ检查显示７８．９％（３０／３８）的患者肿块变小,５例瘤区钙化增加;ＥＣＴ示７９％（     

Changes in the National Endovascular Management of Femoropopliteal Arterial Disease: An Analysis of the 2011–2019 Medicare Data

PurposeTo describe national trends in the utilization of endovascular approaches (including balloon angioplasty, atherectomy, and stent placement) for the management of femoropopliteal peripheral arterial disease (PAD).Materials and MethodsThe Medicare Physician/Supplier Procedure Summary dataset containing 100% of Part B claims was interrogated for years 2011–2019. The Current Procedural Terminology codes specific for femoropopliteal angioplasty, stent placement, and atherectomy were used to create summary statistics for utilization by year, place of service (hospital inpatient, hospital outpatient, and office-based laboratory), and provider specialty (cardiology, radiology, and surgery).ResultsThe use of atherectomy increased from 34,732 (33%) procedures in 2011 to 75,435 (53%) procedures in 2019, and atherectomy became the dominant treatment strategy for femoropopliteal PAD. The relative utilization of stent placement (36,793 [35%] to 28,899 [20%]) and angioplasty only (34,398 [32%] to 38,228 [27%]) decreased concomitantly from 2011 to 2019. By 2019, the use of atherectomy was twofold higher in office-based laboratories than in the outpatient hospital setting (44,767 and 20,901, respectively). Treatment strategy varied by provider specialty in 2011 when cardiologists used atherectomy most frequently (17,925 [43%]), whereas radiologists used angioplasty alone (5,928 [6%]) and surgeons stented (18,009 [37%]) most frequently. By 2019, all specialties utilized atherectomy most frequently (29,564 [59%] for cardiology, 10,912 [58%] radiology, and 33,649 [47%] surgery).ConclusionsThe national approach to endovascular management of femoropopliteal PAD has changed since 2011 toward an implant-free strategy, including a multifold increase in the use of atherectomy. Discordant rates of atherectomy use between the ambulatory hospital and office-based settings highlight the need for comparative effectiveness studies to guide management.     

A Comparison of Liver-Directed Therapy and Systemic Therapy for the Treatment of Liver Metastases in Patients with Gastrointestinal Neuroendocrine Tumors: Analysis of the California Cancer Registry

PurposeTo compare the outcomes of patients with gastrointestinal neuroendocrine tumor liver metastases treated with liver-directed therapy (LDT) to those treated with systemic therapy (ST) in a statewide cancer database.Materials and MethodsA retrospective study was performed of patients with metastatic gastrointestinal tract neuroendocrine tumors treated with either LDT or ST alone between the years 2000–2012 in the California Cancer Registry. Overall survival and disease-specific survival were assessed using multivariable Cox proportional hazards analysis and propensity score matching.ResultsA total of 154 patients (ST, n = 87 and LDT, n = 67) were studied. The median overall survival and disease-specific survival for patients that received ST was 29 and 35 months versus 51 and >60 months for patients that received LDT. On multivariate analysis, LDT and the resection of the primary tumor were associated with improved survival (hazard ratio [HR] 0.52, P = .002; HR 0.43, P = .001). Non-white race, Medicaid/uninsured status, and the presence of lung metastases were associated with poor survival (HR 1.76, P = .014; HR 2.29, P = .009; and HR 1.79, P = .031). Propensity score matching demonstrated an improvement in disease-specific survival for LDT compared to ST (HR 0.53, P = .036). The improvement in overall survival on propensity score matching did not achieve statistical significance (HR 0.70, P = .199).ConclusionsLDT is associated with improved overall and disease-specific survival as compared to ST in patients with gastrointestinal neuroendocrine tumor liver metastases. Further investigation is needed to determine whether combination or sequential treatment can improve outcomes in this population.