Initial single centre experience with Barrel VRD stent in large neck aneurisms

Introduction. Despite the use of new techniques, such as Y-stenting, the waffle-cone technique and intrasaccular flow disrupters the treatment of wide-neck bifurcation aneurysms is still challenging, especially for those where adjacent branches are arising at the neck level. Moreover, the use of flow diverter stents in bifurcation aneurysms has been proposed by several teams, although the results remain controversial.This study is reflecting initial experience in our department with a relatively new device available on the market: Barrel VRD stent. The unique design feature of the device is the “belly-like” central part of the stent which protects the adjacent branches.Methods. We retrospectively reviewed all patients in whom stenting with braided or laser-cut stents had been performed in our center. Three patients were identified and analyzed. Technical success, complications, immediate angiographic outcomes, procedural data, are reported here.Results. One MCA bifurcation and two basilar tip large neck aneurysms with one branch arising from the neck level have been identified. Technical success was achieved in all procedures. Overall procedure-related morbidity and mortality was 0%. In the immediate post-treatment angiography, adequate occlusion (neck remnant or total occlusion) was observed in all patients. Short- and mild-term follow-up angiography showed adequate occlusion of the aneurysms.Conclusions. In this small case series, retrospective single-center analysis we showed that Barrel VRD - stent assisted coiling is a safe and feasible technique. Moreover, it offers an elegant and effective endovascular solution for large neck basilar tip aneurysms on which the neurosurgical clipping remains challenging

Carotid atherosclerosis in a sample of Egyptian patients with or without ischemic vascular events

Abstract Background Ethnic-racial factors are related to the development of extra- and intracranial atherosclerosis. There are extensive data about carotid atherosclerosis from American, European and Asian population. However, data from Egyptian ethnics are extremely rare. We aimed to examine the frequency and determine the predictors of carotid atherosclerosis in a sample of Egyptian patients. In a cross-sectional observational study, we prospectively recruited consecutive patients, with or without ischemic vascular events, either ischemic stroke or transient ischemic attack, who received neurovascular ultrasound in a tertiary hospital. We assessed the presence of carotid plaques and the degree of stenosis according to the hemodynamic North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Results A total of 668 carotid arteries in 334 patients with a mean (IQR) age of 61 (55–70) years were examined; 69.5% presented with and 30.5% without ischemic vascular events. We found carotid plaques in 208 (31.1%) arteries among 147 (44%) patients; 32% of the patients showed non-hemodynamically significant plaques, whereas 3.6% showed 20–40% internal carotid artery (ICA) stenosis and 8.4% showed ≥ 50% ICA stenosis. In patients with ischemic vascular events and at least one risk factor, we detected carotid atherosclerosis, 20–40% ICA stenosis and ≥ 50% ICA stenosis in 40.4%, 3% and 9.1% among patients ≤ 60 years as well as in 64.8%, 5.5% and 13% among patients > 60 years, respectively. In an age and sex adjusted binary logistic regression model, the following factors predicted carotid atherosclerosis: age > 60 years (OR 3.33, 95% CI 1.99–5.57, p < 0.001), hypertension (OR 2.3, 95% CI 1.32–4.02, p = 0.003), current smoking (OR 2.27, 95% CI 1.13–4.55, p = 0.02), diabetes mellitus (OR 2.15, 95% CI 1.27–3.64, p = 0.004) and ischemic vascular events (OR 1.8, 95% CI 1.01–3.19, p = 0.046). Conclusions Among Egyptians, the frequency of carotid atherosclerosis seems to be low. Further multiethnic studies are warranted to compare the prevalence of carotid atherosclerosis among Egyptians with Whites and Chinese populations. Older age, hypertension, smoking, diabetes mellitus and ischemic vascular events are predictors of carotid atherosclerosis

Abstract 1122‐000068: Basilar Artery Occlusion Thrombectomy Between Evidence Based Medicine and the Real‐World Practice, Single Centre Experience

Introduction: BAO (basilar artery occlusion) is well known by catastrophic outcomes whether death or disability in approximately 70 %. 1 Thrombectomy as an intervention in large vessel occlusion of anterior proximal circulation was approved after multiple RCTs and meta‐analyses.2 In spite of two RCTs that appeared lately, there is still uncertainty about the effect of thrombectomy in BAO. 9, 10 Our study aims to report the outcome of BAO, as a further clue of MT effectiveness in BAO and variables affecting good outcome and mortality rate. Methods: We retrospectively collected the clinical and radiological data of 30 BAO patients treated in our center between 2016 and 2020. There is no limitation as regard age or presenting NIHHS. Twenty‐two patients who came to the emergency within 4.5 hours had I.V. thrombolytic therapy (73.3%). A favorable clinical outcome was considered if mRS ≤ 2. Angioplasty, stenting, or I.A thrombolysis were used as a rescue treatment. Symptomatic intracranial hemorrhage within two days after the initiation of treatment and mortality at 90 days were reported. The radiological outcome was assessed by modified Thrombolysis in Cerebral Infarction (mTICI) score where mTICI ≥ 2b or 3 at the end of the intervention was considered a favorable radiological result. Multiple variables were tested for their effect on favorable clinical outcomes and mortality (Table 1). Results: Among 30 patients, the mean age was 61.23 ± 16.81 years; 20/30 (66.7%) male. A favorable functional outcome was achieved in (40.7%). Successful revascularization was achieved in 26 patients (86.7 %). Four patients had procedural complications (13.3%). Symptomatic intracranial hemorrhage occurred in three cases (11%) and mortality at 90 days was 11 patients (36.7 %). The presenting NIHSS is the only predictor of mortality and the optimal cut‐off value for death was 15 with AUC = 0.758 (sensitivity 91 % and specificity 59%) and p‐value = 0.02. TOR (time of onset to recanalization) had no effect on the clinical outcome which is controversy with the paradigm of early reperfusion leading to a good outcome Conclusions: In spite of two RCSs approved no statistical difference between medical treatment and thrombectomy, thrombectomy is still an effective procedure in real‐world practice in selected cases. The presenting NIHSS is the only predictor of mortality in our studies. More studies are warranted to discover other predictors of BAO thrombectomy outcome to improve case selection and avoid futile recanalization

Abstract 1122‐000071: Large and Giant Intracranial Aneurysms, Clinico‐Radiological Outcome and Predictors with Flow Diverter Stent

Introduction: Endovascular treatment for large and giant aneurysms has included either a reconstructive approach or a deconstructive approach by parent artery occlusion. 1,2 Stent‐assisted coiling and balloon‐assisted coiling were alternative techniques developed to deal with such complex aneurysms, but studies have shown less expected efficacy. This study aims to assess the safety and efficacy of the flow diverter stents for treating large and giant intracranial aneurysms and to examine possible predictors for radiological and clinical outcomes such as location and presence of branching artery, bifurcation, and adjuvant coiling. Methods: This study had been conducted on 65 consecutive patients with 65 large and giant aneurysms (size ≥ 10 mm) treated with flow diverters; Periprocedural complications were reported in all patients and clinical outcomes. Follow‐up angiography was done for 60 patients (92.3%) at 12 months. Results: The study included 65 patients who harbored 65 aneurysms. The median age was 55.5 years (IQR: 44.25 ‐ 62.75 years), the female represented 70.8 % of all patients. The clinical presentation had been reported (Headache, cranial nerve palsy, motor deficit, seizures, and visual field defect in 40 patients (61.5%), nine patients (13.8%), seven patients (10.8%), five patients (7.7%), and four patients (6.2%) respectively. The vascular risk factors had been reviewed (HTN, DM, smoking, and Hyperlipidemia in 25 patients (9.2%), Six patients (9.2%), sixteen (24.6%), and 10 patients (15.4%) respectively). The median size of aneurysms was 16.4 mm (IQR: 12.50 ‐ 23.85 mm) and the median neck width was 7.15 mm (IQR: 5.85‐10.24 mm). Fourteen aneurysms (21.4 %) had previous treatment, eleven aneurysms (16.9%) were treated by coils only, one case (1.5%) by assisted procedure, one case (1.5%) by previous FDS, and parent artery occlusion in one case (1.5%). Complete occlusion in 50 from 60 aneurysms (83.4%), neck remnant in 8 aneurysms (13.3%), and sac remnant in two aneurysms (3.3%). Periprocedural problems were encountered in 14 patients (21.5%) with morbidity in six patients (9.2%) and mortality in one patient (1.5%). Univariate and multivariate logistic regression analysis was used to discover possible predictors of combined mortality and morbidity and occlusion in Table (1). Conclusions: From this study, it could be concluded that Endovascular treatment of the large and giant aneurysms with flow diverters represents a safe method for treating this kind of complex intracranial aneurysms. Complex aneurysms with branching artery and bifurcation were associated with aneurysm persistence and complications respectively while the location of the aneurysm was the only predictor for clinical outcome

Y-stenting with braided stents for wide-neck intracranial bifurcation aneurysms. A single-center initial experience

The treatment of wide-neck bifurcation aneurysms is still challenging despite the use of new techniques, such as Y-stenting, the waffle-cone technique and intrasaccular flow disrupters, in recent years. Moreover, the use of flow diverter stents in bifurcation aneurysms has been proposed by several teams, although the results remain controversial. This study aims to evaluate the feasibility and efficacy of Y-stent assisted coiling of bifurcation aneurysms with braided stents

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry

BACKGROUND AND OBJECTIVES: COVID-19 related inflammation, endothelial dysfunction and coagulopathy may increase the bleeding risk and lower efficacy of revascularization treatments in patients with acute ischemic stroke. We aimed to evaluate the safety and outcomes of revascularization treatments in patients with acute ischemic stroke and COVID-19. METHODS: Retrospective multicenter cohort study of consecutive patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021, tested for SARS-CoV-2 infection. With a doubly-robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS: Of a total of 15128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19. 5848 (38.7%) patients received IVT-only, and 9280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted odds ratio [OR] 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour (OR 2.47; 95% CI 1.58-3.86) and 3-month mortality (OR 1.88; 95% CI 1.52-2.33).COVID-19 patients also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION: Patients with acute ischemic stroke and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 treated patients. Current available data does not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in COVID-19 patients, or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring and establishing prognosis

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry.

BACKGROUND AND OBJECTIVES COVID-19 related inflammation, endothelial dysfunction and coagulopathy may increase the bleeding risk and lower efficacy of revascularization treatments in patients with acute ischemic stroke. We aimed to evaluate the safety and outcomes of revascularization treatments in patients with acute ischemic stroke and COVID-19. METHODS Retrospective multicenter cohort study of consecutive patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021, tested for SARS-CoV-2 infection. With a doubly-robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS Of a total of 15128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19. 5848 (38.7%) patients received IVT-only, and 9280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted odds ratio [OR] 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour (OR 2.47; 95% CI 1.58-3.86) and 3-month mortality (OR 1.88; 95% CI 1.52-2.33).COVID-19 patients also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION Patients with acute ischemic stroke and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 treated patients. Current available data does not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in COVID-19 patients, or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring and establishing prognosis

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially