Faculty Bibliography

Introduction: Eptifibatide (Integrilin) has been demonstrated to improve clinical outcomes in both intracoronary and carotid artery stenting, when administered perioperatively. This evidence promotes the investigation of eptifibatide's role in neuroendovascular stenting. Methods: 38 patients between 2013-2017 underwent intracranial stenting with eptifibatide administration within 24 hours of procedure. Cumulative and average eptifibatide dosages were determined for all patients. Peri and post-procedural bleeding complications were defined as intercranial hemorrhage (ICH), symptomatic intercranial hemorrhage (sICH), and peripheral bleeding (retroperitoneal, access site bleeding, GI bleeding). Final Thrombolysis in Cerebral Infarction (TICI) scores as well as modified Rankin Scales (mRS) at discharge were also collected. Comparisons of these outcomes were made between patients with high-dose Integrilin and low-dose Integrilin, which we defined as above or equal to and below 0.75 mcg/kg/ min, respectively. A similar comparison was performed for patients who received above and below calculated dosage of median cumulative dose (0.71 mg/kg) Results: Of all 38 patients, 7 (21.8%) patients were found to have intracerebral hemorrhage, with 3 of these patients showing symptoms. Additionally, 6 patients (18.7%) experienced peripheral bleeding complications. Mean eptifibatide dosage was determined to be 0.77 mcg/kg/min. Analysis of the primary endpoint of all-cause bleeding complications yielded no significance between high-dose and low-dose Integrilin (p > 0.05). However, the incidence of sICH was significantly greater in patients receiving an average dosage at 0.75 mcg/kg/min or higher (p < 0.05). Furthermore, angiographic assessment revealed that more patients who receive a cumulative dosage of 0.71 mg/kg or greater achieved a TICI score of 2c-3 in comparison to those who achieved TICI 2b (p < 0.05). Conclusions: Usage of eptifibatide for patients undergoing neurovascular stenting at higher average dosages may result in a higher incidence of symptomatic ICH, however higher cumulative dosages may improve angiographic outcomes

Introduction: Subclavian steal syndrome (SSS) is usually due to stenosis of the Subclavian Artery (SA) proximal to the origin of the vertebral artery (VA). SSS with intact SA in patients with dialysis arterio-venous fistulas (AVF) has been occasionally reported[1-4]. We present a unique case of the same successfully treated with a covered stent. Methods: A 65-year-old male with DM, HTN, ESRD and left brachial artery- basilic vein fistula (2.27 L/min flow) had multiple admissions with vertebrobasilar symptoms in the setting of elevated BP. Repeated evaluations with CT/CTA/MRI were negative for steno-occlusive disease or infarction. Therefore, symptoms were attributed to hypertensive urgency. On his third presentation in 4 months, he had additional symptoms of left arm pain, weakness and numbness. Signs included left arm hyperemia, warmth and mild motor-sensory deficits. Results: MRA demonstrated reverse flow of blood in left VA with focal stenosis of proximal left SA. Angiogram showed a kinked LSA and rapid/ early shunting to the subcalvian vein. There was no ante-grade visualization of the LVA with reverse flow from the RVA via VB junction. However on compression of the shunt with a BP cuff, antegrade flow in LVA reappeared with disappearance of RVA-LVA steal. BP transduction revealed a 50-mmHg point difference across the kinked segment. Subsequently, proximal left SA was stented with a covered biliary stent resulting in disappearance in RVALVA & LSA-LSV shunts, reappearance of antegrade LVA flow and resolution of symptoms. Conclusions: High-flow AVF is an underdiagnosed cause of symptomatic SSS. We suggest determining AVF flow speeds in any hemodialysis patient who presents with symptoms of posterior circulation insufficiency and obtaining noninvasive vascular studies if flow exceeds 2 L/min or if there has been a recent increase in measured flow during hemodialysis. Obtaining vascular studies with and without fistula compression could be of additional diagnostic utility

Introduction: The efficacy of MDCT-based-angiography in management of acute stroke and/or emergent-large-vessel-occlusion is well established. However, concern for contrast-induced nephropathy(CIN) especially in patients with major risk factors like Diabetes & Chronic kidney disease often delays rapid evaluation of ELVO patients. Many published studies report the overall incidence of CIN after administration of IV or IA iodinated contrast and highlight the direct correlation of dose on higher incidence of CIN. None, however, have examined impact of sequential IV-IA bolus for neuroangiographic evaluation on renal function in patients with DM and/or CKD. Methods: A retrospective study of our 2015-2017 stroke database of 168 patients was conducted to identify all patients with preexisting DM and/or CKD who developed CIN during their hospital course. We also reviewed the prevalence of dehydration (BUN/Cr <20), CHF and anemia (Hb <8 g/dL) for these patients on admission. Results: For all 168 patients; average IA, IV and cumulative IV-IA contrast (Omnipaque 350) doses within 24 hours were 89.9, 91.7 and 181.6 cc respectively. 68 patients had DM and/or CKD of which 3 developed CIN. Under the definition of >=25% increase in baseline Cr within 72-120 hours of receiving contrast, all 3 had CIN. However, under the definition of >=0.5 mg/dL increase in Cr within 72 hours, none had CIN. All 3 only had preexisting DM as risk factor and had age appropriate baseline Cr on admission. The baseline Cr for each of the 3 patients were 0.82, 1.17 & 0.47 mg/dL respectively while the elevated Cr were 1.03, 1.17 & 0.76 mg/dL respectively. All 3 returned to within baseline by discharge with no mortality or need for hemodialysis. Conclusions: There is low risk of developing CIN in high risk patients like CKD or DM following rapid sequential dual IV/IA contrast bolus in acute stroke patients and therefore should not delay rapid neuro-angiographic evaluation

A large number of patients presenting with acute ischemic stroke have large artery intracranial occlusions, and timely recanalization of these occlusions often leads to improved neurologic outcome. Starting with the widespread use of IV tissue plasminogen activator, a wide variety of pharmacologic and mechanical methods have been introduced to improve vessel recanalization and clinical outcome of patients with acute ischemic stroke, which include endovascular therapies such as intra-arterial thrombolytics and mechanical thrombectomy devices. One of the potential therapies is angioplasty and stenting, and this has been evaluated in multiple case reports and small series published by various centers regarding its use in this setting. In this article, we review the current literature on stenting with and without angioplasty, used alone or as a part of multimodal therapy for recanalization for acute cerebrovascular occlusions.

BACKGROUND AND OBJECTIVE: The outcome of failed recanalization in patients with acutely symptomatic intracranial vertebrobasilar (VB) artery occlusive disease is poor. This paper reports the recanalization rate and safety of VB artery stenting in acutely symptomatic patients presenting >8 h after onset of symptoms. METHODS: A retrospective review of a prospectively maintained database of stent-supported endovascular treatment of intracranial circulation was carried out to identify patients with VB artery occlusive disease who were acutely revascularized >8 h after symptom onset. RESULTS: Of 12 patients (mean age 61 years), nine had acute stroke and three had recurrent transient ischemic attacks. The median time to intervention was 59 h (range 8-80). The median National Institute of Health Stroke Scale score was 11.5 (range 1-40). Angiography showed thrombolysis in myocardial infarction (TIMI) 0 flow in six patients and TIMI 1 flow in the other six. Stents were placed in the basilar artery in six and at the VB junction in the other six. Mechanical and/or intra-arterial thrombolysis was used in three patients before stenting. Nine patients had self-expanding stents and three had balloon-expandable stents. The recanalization rate was 100%. Procedure-related and 3-month mortality was zero. Two patients had asymptomatic intracranial hemorrhage. At 3-month follow-up a favorable outcome with a modified Rankin score