The experience of surgery and endovascular procedure of cerebrovascular disease in the hybrid operating room; Multi-axis robotic C-arm DSA system

Chang Hyeun Kim,이상원,Young Ha Kim,성순기,손동욱,송근성 대한뇌혈관외과학회 2020 Journal of Cerebrovascular and Endovascular Neuros Vol.22 No.4

Objective: To report on combined surgical and/or endovascular procedures for cerebrovascular disease in a hybrid operating room (OR). Methods: Between October 2016 and June 2020, 1832 neurosurgical procedures were performed in a hybrid OR. Our institution’s hybrid OR consists of a multi-axis robotic C-arm monoplane digital subtraction angiography (DSA) system with an operating table, 3D-rotational DSA, cone-beam computed tomography (dyna CT), and real-time navigation software. Procedures were categorized into six categories according to purpose: (1) simple diagnosis and follow-up, (2) simple endovascular procedure, (3) combination of surgery and endovascular procedures, (4) rescue surgery after endovascular procedures, (5) frameless stereotactic procedure, and (6) other surgeries requiring C-arm. Results: Of 1832 neurosurgical procedures in the hybrid OR, 1430 were simple diagnosis and follow-up cases, 330 simple endovascular procedures, 8 combination of surgery and endovascular procedures, 15 rescue after endovascular procedure, 40 frameless stereotactic procedures, and 9 other surgeries. Eight cases of combination of surgery and endovascular procedures, safely performed without wasting time on patient transfer, were performed in seven bypass end endovascular procedures and one case of bow-hunter syndrome in complex cerebrovascular disease. After embolization, craniotomy (or craniectomy) and intracerebral hemorrhage removal were performed in eight patients in-situ. Of the 40 frameless stereotactic procedure, 37 were extraventricular drainage before/after coil embolization in subarachnoid hemorrhage patients. They all mounted conduits in their planned locations. Conclusions: A hybrid OR for combined endovascular and surgical procedures represents a safe and useful strategy for cerebrovascular disease. In hybrid ORs various neurosurgical procedures can be safely and conveniently performed. Hybrid OR will pioneer a new era in neurosurgical procedures.

Results of Endovascular Coil Embolization Treatment for Small (≤ 5 mm) Unruptured Intracranial Aneurysms

Siwoo Lee,Tae-Sik Gong,Yong-Woo Lee,Hyo-Joon Kim,Chang-young Kweon 대한뇌혈관외과학회 2016 Journal of Cerebrovascular and Endovascular Neuros Vol.18 No.3

Objective : Researchers and clinicians have been unable to fully elucidate the natural course of and proper treatment for unruptured intracranial aneurysms (UIAs) smaller than or equal to 5 mm, particularly with regard to whether close observation or surgery is more appropriate. In this retrospective study, we evaluated the safety and efficacy of endovascular coil embolization of small (≤ 5 mm) asymptomatic UIAs by analyzing outcomes and complications associated with the procedure. Materials and Methods : We analyzed data from 150 patients with small asymptomatic UIAs (≤ 5 mm) treated with coil embolization between January 2011 and December 2015. Three-dimensional angiography was used to measure aneurysm size. We evaluated procedure-related morbidity and mortality, immediate post-operative angiographic results, brain computed thomography follow-up results on post-operative day one, and clinical progress. Results : UIAs occurred primarily in the anterior circulation area (142 cases, 94.67%), though eight patients exhibited UIAs of the posterior circulation. Following coil embolization, aneurysms with complete occlusion were observed in 137 cases (91.3%). Partial occlusion occurred in five cases (3.33%), while the procedure had failed in eight cases (5.33%). Procedure-related morbidity and mortality were five cases (3.33%) and zero cases, respectively. Conclusion : The endovascular treatment of small asymptomatic UIAs is associated with good short-term outcomes without permanent neurologic complications as well as low overall complication and morbidity rates. Thus, the procedure should be considered for patients with smaller asymptomatic UIAs.

Ticagrelor Use in Indian Patients Undergoing Neuroendovascular Procedures: A Single Center Experience

Karan Vivek,Vyas Devashish,Bohra Vikram,Huded Vikram 대한신경중재치료의학회 2019 Neurointervention Vol.14 No.2

Purpose: A safe and efficacious antiplatelet drug is needed for patients with clopidogrel resistance who undergo neuroendovascular procedures. Ticagrelor is a new reversibly binding, oral, direct-acting P2Y receptor antagonist with no known resistance. We describe our clinical experience using ticagrelor for neuroendovascular procedures in Indian patients with clopidogrel resistance at the NH Institute of Neurosciences, Narayana Health City, Bangalore. Materials and Methods: We retrospectively reviewed our endovascular procedure database for all patients with predefined clopidogrel resistance. Clopidogrel resistance was defined as P2Y12 inhibition <40%. Patients were administered ticagrelor along with aspirin prior to the procedure. Results: Of 127 patients, 32 (25%) were non-responders to clopidogrel (22 [69%] males, 10 [31%] females; median age, 54 years [range, 20–75]). All patients were treated with a 180-mg loading dose of ticagrelor, followed by 90 mg twice daily. Twenty patients (63%) underwent endovascular intervention for intracranial aneurysm, two (6%) for dissecting aneurysms, nine (28%) for stenotic lesions, and one (3%) for carotico-cavernous fistula. No patient experienced any adverse effects related to the use of Ticagrelor in the postoperative period. Conclusion: Ticagrelor is an effective alternative to clopidogrel for use in conjunction with aspirin in patients with clopidogrel resistance. None of our patients had adverse effects from ticagrelor. Drug cost, twice-daily dosing, and risk of faster platelet aggregation activation after discontinuation should be taken into consideration prior to its use in such patients.

흉부대동맥 질환에서 시행된 하이브리드 혈관내 성형술의 중단기 성적

윤영남,김관욱,홍순창,이삭,장병철,송승준 대한흉부외과학회 2010 Journal of Chest Surgery (J Chest Surg) Vol.43 No.5

Background: A hybrid procedure using an open surgical extra-anatomic bypass of aortic arch vessels and thoracic endovascular aortic repair (TEVAR) is less invasive than open surgery, and provides a suitable proximal landing zone. Here we report our experience with a hybrid TEVAR procedure at a single center. Material and Method: We retrospectively reviewed consecutive patients with thoracic aortic disease who received a hybrid TEVAR procedure between August 2008 and January 2010. Patients’ data were prospectively collected and mean follow-up was 10.8±5.5 months (range 3∼20). Result: Nine patients (7 males and 2 females) with a mean age of 63.8±15.8 years (range 38∼84) underwent a hybrid procedure. Five patients had an arch or a proximal descending aortic aneurysm, two had a dissecting aneurysm of the descending aorta, and two had an aneurysm of the ascending arch and descending aorta. Mean expected mortality calculated by logistic EuroSCORE was 21%. Six patients underwent debranching and rerouting from ascending aorta to arch vessels, 2 had carotid-carotid bypass grafting, and 1 underwent carotid-axillary bypass grafting. Mean operation time was 221.4±84.0 min (range 94∼364). Deployment success of endovascular stent grafting was 100% with no endoleak on completion angiography. There was no mortality, and a small embolism in the branch of the right opthalmic artery in one patient. During follow-up, one intervention was required for the endoleak. Actuarial survival at 20 months was 100%. Conclusion: Early and mid-term results are encouraging and suggest that hybrid TEVAR procedures are less invasive and safer and represent an effective technique for treating thoracic aortic disease. 배경: 대동맥궁 분지 혈관의 해부학적 외 우회로술(extra-anatomic bypass)과 흉부 혈관내 대동맥 스텐트 도관 삽입술을 같이 시행하는 하이브리드 술식은 고식적인 완전 개방 수술에 비해 덜 침습적이며, 스텐트 도관 삽입술 시 안정된 안착지점(landing zone)을 확보할 수 있는 장점을 가지는 것으로 알려져 있다. 저자들은 본원에서 시행된 하이브리드 술식의 중단기 성적에 대하여 알아보고자 하였다. 대상 및 방법: 2008년 8월부터 2010년 1월까지 흉부대동맥 질환의 치료를 위해 하이브리드 술식을 시행한 일련의 환자들을 대상으로 하였다. 환자의 수술 전 후 데이터는 전향적으로 수집하였으며, 평균 추적관찰 기간은 10.8±5.5개월(3∼20개월)이었다. 결과: 9명의 환자(남:여=7:2)에서 하이브리드 술식이 시행되었으며, 평균 나이는 63.8±15.8세 (38∼84세)였다. 5명에서 대동맥궁 혹은 근위 하행대동맥류가 있었으며, 2명의 환자에서 하행대동맥에 박리성 동맥류가, 2명에서 상행 대동맥, 대동맥궁, 및 하행대동맥에 광범위한 동맥류가 관찰되었다. 수술 전, logistic EuroSCORE로 계산한 평균 예측사망률은 21%였다. 6명에서 상행 대동맥으로부터 대동맥궁 분지혈관으로 탈분지화 및 재혈관화를 시행하였으며, 2명에서 경동맥-경동맥 우회로술, 1명에서 경동맥-액와동맥 우회로술을 시행하였다. 평균 수술 시간은 221.4±84.0분(94∼364분)이었다. 수술 후 100%의 환자에서 전산화 단층 혈관촬영을 통하여 스텐트 도관의 성공적인 안착을 확인하였으며, 총 평균재원일수는 15.2±4.6일이었다. 수술 후 사망은 없었다. 1명에서 우측 안동맥 분지에 색전증이 발생하였고 이외 합병증은 없었다. 추적관찰 기간 중 1명에서 스텐트 근위부의 endoleak으로 재시술을 시행하였으며, 20개월 생존율은 100%이었다. 결론: 흉부대동맥 질환의 치료에 있어 하이브리드 술식은 덜 침습적이고 효과적인 치료이다. 본 연구의 중단기 성적을 토대로 보아 하이브리드 술식은 고무적인 치료법으로 사료된다.

Dual Mechanical Thrombectomy for Recanalization of a Resistant Acute Posterior Circulation Stroke

Ahmet Peker,Anil Arat,Ayça Akgoz,Ethem Murat Arsava,Mehmet Akif Topçuoglu 대한뇌혈관외과학회 2017 Journal of Cerebrovascular and Endovascular Neuros Vol.19 No.2

A 71-year-old man with acute basilar artery occlusion was referred for endovascular treatment 6 hours after the onset of stroke with a Glasgow Coma Score of 3 and National Institutes of Health Stroke Scale of 27. A cerebral arteriogram revealed occlusion of the left vertebral artery proximally and thromboembolic occlusion of the basilar tip. Direct aspiration and mechanical thrombectomy with various stent retrievers failed to reconstitute arterial flow in the basilar artery. Thrombolysis in cerebral infarction 2b recanalization was achieved only after placement of double Catch Mini stent retrievers through 2 microcatheters, on both side branches of the basilar bifurcation in a kissing fashion and retrieving them simultaneously. It was possible to perform this maneuver through a single distal access catheter without any complications. On follow-up the patient awakened and was able to follow commands on his right side. To our knowledge, dual mechanical thrombectomy with stent retrievers has not been reported in the posterior circulation previously. This technique may be useful in retrieving thrombi located at major intracranial bifurcations of the posterior circulation which do not recanalize with standard mechanical thrombectomy procedures. Although bilateral access to the basilar artery through both vertebral arteries is an advantage in posterior circulation for this technique, dual mechanical thrombectomy can also be performed through a unilateral access.

Procedure-related Complication Rate for the Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhage under Local Anesthesia

Soo-Dong Park,Jong-Hoon Kim,Chul-Hoon Chang,Young Jin Jung 대한뇌혈관외과학회 2016 Journal of Cerebrovascular and Endovascular Neuros Vol.18 No.3

Objective : To report the procedure related complication rate of endovascular treatments (EVTs) performed on patients with aneurysmal subarachnoid hemorrhage (aSAH) under local anesthesia (LA). Materials and Methods : This study enrolled 186 patients who underwent EVT for ruptured aneurysm under LA from January 2009 to December 2013. Procedure-related complications rate and factors associated with it were analyzed depending on the patients' factors, aneurysm factors and physician factors. Results : Among the 186 patients who underwent EVT under LA, the respective rates of thromboembolic complication (TEC) and intraoperative rupture (IOR) were 12.8% (23 cases) and 12.9% (24 cases), respectively. Aneurysm size (≥ 7 mm) was the only risk factor for TEC (p = 0.048). Conclusion : Compared to previous result with under general anesthesia (GA), the rate of TEC was similar in patients treated under LA, but the IOR rate was significantly higher. The main reason for increasing IOR is considered as the unexpected patients' motion and in accordance with the unexpected movement of the microinstruments. Therefore, another methods to stabilize the patients or switching from LA to GA may be necessary when performing EVT, to reduce complications.

Y-stent-assisted coiling with Neuroform Atlas stents for wide-necked intracranial bifurcation aneurysms: A preliminary report

Kim Dongkyu,Chung Joonho 대한뇌혈관외과학회 2022 Journal of Cerebrovascular and Endovascular Neuros Vol.24 No.1

Objective: To report our experience on Neuroform Atlas Y-stenting for coiling of unruptured wide-neck bifurcation aneurysms. Methods: From March 2018 to January 2021, we treated 473 aneurysms in 436 patients with coil embolization, of which 15 cases with wide-necked bifurcation aneurysms were treated by Y-stent-assisted coiling with two Neuroform Atlas stents. We retrospectively reviewed the characteristics of patients and aneurysms, procedure-related complications, radiographic results, and clinical outcomes. Results: All 15 cases using Neuroform Atlas Y-stenting were successful. Patients included 6 men and 9 women with a mean age ± standard deviation of 56.4±6.6 years. The mean dome and neck sizes were 6.4±3.1 mm and 4.7±1.8 mm, respectively. Immediate post-procedural angiograms showed complete occlusion in 46.7%, neck remnant in 13.3%, and incomplete occlusion in 40% of cases. No treatment-related morbidity or mortality occurred in any patients. All patients had good clinical outcomes (Glasgow Outcome Score 5) at both discharge and during a mean 12.3-month (range 1-28 months) follow-up. All aneurysms showed improved or stable occlusion on follow-up imaging. Further, the latest follow-up angiography showed complete occlusion in 73.3%, neck remnant in 6.7%, and incomplete occlusion in 20%. Conclusions: Y-stent-assisted coiling with Neuroform Atlas stents might be a feasible and safe option for wide-necked bifurcation aneurysms.

Vascular Rupture Caused by a Molding Balloon during Endovascular Aneurysm Repair: Case Report

이희영,도영수,김영욱,박홍석,박광보,김동익 대한영상의학회 2011 대한영상의학회지 Vol.65 No.2

Endovascular aneurysm repair (EVAR) has been accepted as an alternative to traditional open surgery in selected patients. Despite the minimally invasiveness of this treatment, several complications may occur during or after EVAR. Complications include endoleak, aortic dissection, distal embolism, or iatrogenic injury to the access artery. However, there are few reports on the vascular rupture caused by a molding balloon during EVAR. We report two cases of infrarenal abdominal aortic aneurysms complicated by procedure-related aortic or iliac artery rupture by the molding balloon during EVAR. In our cases, we observed suddenly abrupt increase of the diameter of the endograft during balloon inflation, because we inflated the balloon rapidly. In conclusion, careful attention must be paid during inflation of the molding balloon to prevent vascular rupture.

Retrieval of Distally Migrated Coils with Detachable Intracranial Stent during Coil Embolization of Cerebral Aneurysm

Devendra Pal Singh,Soon Chan Kwon,Lijin Huang,Won Joo Lee 대한뇌혈관외과학회 2016 Journal of Cerebrovascular and Endovascular Neuros Vol.18 No.1

Migration of coils during endovascular procedures is a rare, but well-known complication. We are reporting two cases of successfully retrieving migrated coil using detachable intracranial stent. In both of our cases there was distal migration of coil during the intracranial aneurysm coiling procedure. The Solitaire® AB stent (Covidien, Irvine, CA, USA) was used to retrieve those coils. The stent was passed distal to the migrated coil using standard technique. It was then partially deployed and gradually withdrawn along with the entangled coil. Coil retrieval using the fully retrievable intracranial stent is a very simple, safe and easily available alternative for retrieval of distally migrated coil.

Endovascular coil embolization for unruptured intracranial aneurysms in patients over 80 years of

Seok-won Lee,Hyon-Jo Kwon,Eun-Oh Jeong,고현송,Kyung Hwan Kim,Seung Won Choi,Seon-Hwan Kim,염진영 대한뇌혈관외과학회 2020 Journal of Cerebrovascular and Endovascular Neuros Vol.22 No.4

Objective: As the average life span in modern society continues to increase, much interest is focused on high-risk procedures in elderly patients, including major surgical operations. We investigated the results of endovascular coiling of unruptured intracranial aneurysms (UIA) in patients over 80 years of age. Methods: We retrospectively analyzed 39 patients aged over 80 years who underwent coil embolization for UIA between April 2007 and April 2019 at our hospital. Results: Complete occlusion on digital subtraction angiography (DSA) immediately after surgery was performed in 44 (84.6%) of 52 cases of cerebral aneurysms. Four patients (7.7%) had residual aneurysmal necks, and four (7.7%) had contrast flow in the aneurysmal sac. Follow-up magnetic resonance angiography (mean: 8.2 months) was performed in 37 aneurysms in 24 patients. There was evidence of blood flow in the neck in seven cases (18.9%) and aneurysm in two cases (5.4%). Follow-up DSA (mean: 20.5 months) was performed in 14 aneurysms in 11 patients, and 11 aneurysms (78.6%) had complete occlusion, 1 aneurysm (7.1%) had an aneurysmal neck, and 2 aneurysms (14.3%) had contrast filling into the aneurysmal sac. Coil embolization procedure-related complications occurred in 3 patients (7.7%). Cerebral infarction occurred in 1 (2.6%), arterial dissection in 1 (2.6%), and hypoesthesia in 1 (2.6%). Conclusions: Active treatment of UIA in elderly patients over 80 years of age through endovascular coil embolization can be considered.