In-stent stenosis after stent-assisted coiling: incidence, predictors and clinical outcomes of 435 cases

Neuroform and Enterprise are widely used self-expanding stents designed to treat wide-necked intracranial aneurysms. To assess the incidence, clinical significance, predictors, and outcomes of in-stent stenosis (ISS). Angiographic studies and hospital records were retrospectively reviewed for 435 patients treated between 2005 and 2011 in our institution. A multivariable regression analysis was conducted to determine the predictors of ISS. The Neuroform stent was used in 264 patients (60.7%) and the Enterprise in 171 patients (39.3%). A total of 11 patients (2.5%) demonstrated some degree of ISS during the follow-up period at a mean time point of 4.2 months (range, 2-12 months). The stenosis was mild ( 75%) in 1 patient (0.2%). No patients were symptomatic or required further intervention. There was complete ISS resolution in 2 patients, partial resolution in 2 patients, and no change in 5 patients on follow-up angiography. Patients developing ISS were significantly younger than those without ISS (40.3 vs. 54.9 years; P < .001). ISS rates were 2.7% with the Neuroform and 2.3% with the Enterprise stent (P = .6). In multivariable analysis, younger patient age (odds ratio = 0.92; P = .008), carotid ophthalmic aneurysm location (odds ratio = 7.7; P =0.01), and carotid terminus aneurysm location (odds ratio = 8.1; P = .009) were strong independent predictors of ISS. The type of stent was not a predictive factor. Neuroform and Enterprise ISS is an uncommon, often transient, and clinically benign complication. Younger patients and those harboring anterior circulation aneurysms located at ophthalmic and carotid terminus locations are more likely to develop ISS

Abstract 110: Stent-Assisted Coiling of Intracranial Aneurysms: Predictors of Complications, Recanalization, and Outcome in 509 Cases

Introduction: Self-expanding stents are increasingly used for treatment of complex intracranial aneurysms. We assess the safety and efficacy of intracranial stenting and determine predictors of complications, recanalization, and outcome in the largest series of intracranial aneurysms to date. Methods: A total of 509 patients were treated with Neuroform and Enterprise stents between 2005-2011 in our institution. A multivariate logistic regression analysis was conducted to detect predictors of complications, recanalization, and outcome. Results: 445 (87.4%) patients were treated electively and 64 (12.6%) in the setting of subarachnoid hemorrhage. Mean aneurysm size was 7.7 mm. Stent placement was successful in 97.6% of patients. The Neuroform stent was used in 56.8% and the Enterprise stent in 43.2%. Complete or near-complete aneurysm occlusion was achieved initially in 87.7% of cases. Procedural complications occurred in 5.6% of patients. In multivariate analysis, subarachnoid hemorrhage (p=0.03), delivery of coils prior to stent placement (p=0.002), and carotid terminus/middle cerebral artery aneurysm locations (p=0.01) were independent predictors of procedural complications. Angiographic follow-up was available for 85.1% of patients at a mean of 27 months. The rates of recanalization and retreatment were respectively 11.7% and 6.1%. Previously coiled aneurysms (p=0.02), ruptured aneurysms (p=0.01), larger aneurysms (p<0.001), incompletely occluded aneurysms (p=0.01), and cavernous/vertebrobasilar/posterior communicating/middle cerebral artery aneurysms (p=0.04) were predictors of recanalization. Favorable outcomes were seen in 99.3% of elective patients and 61% of subarachnoid hemorrhage patients. Patient age (p=0.03), Hunt and Hess Grades (p<0.001), and procedural complications (p<0.001) were predictors of outcome. The type of stent was not a predictor of complications, recanalization, or outcome. Conclusion: Stent-assisted coiling of ruptured and unruptured intracranial aneurysms is safe, effective, and provides durable aneurysm closure. Stent delivery prior to coil deployment reduces the risk of procedural complications. The type of stent used does not affect treatment outcome

Does Resident Experience Affect Outcomes in Complex Abdominal Surgery?

Background: For complex abdominal operations, the influence of provider and hospital volume on surgical outcomes has been described. The impact of resident experience is less well understood.Methods: We reviewed perioperative outcomes after pancreaticoduodenectomy (PD) at a single high-volume center between 2006 and 2012. Resident participation and outcomes were collected in a prospectively maintained database. Resident experience was defined as post-graduate year (PGY) and number of PDs performed.Results: Twenty-nine residents and four attending surgeons completed 681 PDs. The overall complication rate was 44%; PD-specific complications (defined as pancreatic fistula, delayed gastric emptying, bile leak, abscess, and wound infection) occurred in 28% and were significantly more common when the first assistant was a PGY 4 rather than a PGY 5 or 6 (44% vs. 27%, p=0.016). Logistic regression demonstrated that as residents perform more cases, PD-specific complications decrease (OR=0.97, pConclusions: We highlight the impact of resident involvement in complex abdominal operations, demonstrating that as residents build experience with PD, patient outcomes improve. This is consistent with volume-outcome relationships for attending physicians and high-volume hospitals. Complex cases provide unparalleled learning opportunities and remain an important component of surgical training. Maximizing resident repetitive exposure to complex surgical procedures benefits both the patient and the trainee

Does resident experience affect outcomes in complex abdominal surgery? Pancreaticoduodenectomy as an example.

OBJECTIVES: Understanding the factors contributing to improved postoperative patient outcomes remains paramount. For complex abdominal operations such as pancreaticoduodenectomy (PD), the influence of provider and hospital volume on surgical outcomes has been described. The impact of resident experience is less well understood. METHODS: We reviewed perioperative outcomes after PD at a single high-volume center between 2006 and 2012. Resident participation and outcomes were collected in a prospectively maintained database. Resident experience was defined as postgraduate year (PGY) and number of PDs performed. RESULTS: Forty-three residents and four attending surgeons completed 686 PDs. The overall complication rate was 44 %; PD-specific complications (defined as pancreatic fistula, delayed gastric emptying, intraabdominal abscess, wound infection, and bile leak) occurred in 28 % of patients. The overall complication rates were similar when comparing PGY 4 to PGY 5 residents (55.3 vs. 43.0 %; p \u3e 0.05). On univariate analysis, there was a difference in PD-specific complications seen between a PGY 4 as compared to a PGY 5 resident (44 vs. 27 %, respectively; p = 0.016). However, this was not statistically significant when adjusted for attending surgeon. Logistic regression demonstrated that as residents perform more cases, PD-specific complications decrease (OR = 0.97; p \u3c 0.01). For a resident\u27s first PD case, the predicted probability of a PD-specific complication is 27 %; this rate decreases to 19 % by resident case number 15. CONCLUSIONS: Complex cases, such as PD, provide unparalleled learning opportunities and remain an important component of surgical training. We highlight the impact of resident involvement in complex abdominal operations, demonstrating for the first time that as residents build experience with PD, patient outcomes improve. This is consistent with volume-outcome relationships for attending physicians and high-volume hospitals. Maximizing resident repetitive exposure to complex procedures benefits both the patient and the trainee