Are routine intensive care admissions needed after endovascular treatment of unruptured aneurysms?
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ABSTRACT: Summary
Routine intensive care unit monitoring is common after elective embolization of unruptured intracranial aneurysms. In this series of 200 consecutive endovascular procedures for unruptured intracranial aneurysms, 65% of patients were triaged to routine (non-intensive care unit) floor care based on intraoperative findings, aneurysm morphology, and absence of major co-morbidities. Only 1 patient (0.5%) required subsequent transfer to the intensive care unit for management of a perioperative complication. The authors conclude that patients without major co-morbidities, intraoperative complications, or complex aneurysm morphology can be safely observed in a regular ward rather than being admitted to the intensive care unit.
SUBMITTER: Burrows AM
PROVIDER: S-EPMC7964848 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundPreventing errors and complications in neurointervention is crucial, particularly in the treatment of unruptured intracranial aneurysms (UIAs), where the natural history is generally benign, and the margin of treatment benefit small. We aimed to investigate how neurointerventionalists perceive the importance and frequency of errors and the resulting complications in endovascular UIA treatment, and which steps could be taken to prevent them.MethodsAn international multidisciplinary survey was conducted among neurointerventionalists. Participants provided their demographic characteristics and neurointerventional treatment volume. They were asked about their perceptions on the importance and frequency of different errors in endovascular UIA treatment, and which solutions they thought to be most effective in preventing these errors.ResultsTwo-hundred-thirty-three neurointerventionalists from 38 countries participated in the survey. Participants identified errors in technical execution as the most common source of complications in endovascular UIA treatment (40.4% thought these errors constituted a relatively or very large proportion of all complication sources), closely followed by errors in decision-making/indication (32.2%) and errors related to management of unexpected events (28.4%). Simulation training was thought to be most effective in reducing technical errors, while cognitive errors were believed to be best minimized by abandoning challenging procedures, more honest discussion of complications and better standardization of procedure steps.ConclusionNeurointerventionalists perceived both technical and cognitive errors to be important sources of complications in endovascular UIA treatment. Simulation training, a cultural change, higher acceptance of bail-out strategies and better standardization of procedures were perceived to be most effective in preventing these.
| S-EPMC7645194 | biostudies-literature
Project description:BackgroundWe aimed to assess the feasibility of using supraglottic devices as an alternative to orotracheal intubation for airway management during anesthesia for endovascular treatment of unruptured intracranial aneurisms in our department over a nine-year period.MethodsRetrospective single center analysis of cases (2010-2018). Primary outcomes: airway management (supraglottic device repositioning, need for switch to orotracheal intubation, airway complications).Secondary outcomesaneurysm complexity, history of subarachnoid hemorrhage, hemodynamic monitoring, and perioperative complications.ResultsWe included 187 patients in two groups: supraglottic device 130 (69.5%) and orotracheal intubation 57 (30.5%). No adverse incidents were recorded in 97% of the cases. Three supraglottic device patients required supraglottic device repositioning and 1 supraglottic device patient required orotracheal intubation due to inadequate ventilation. Three orotracheal intubation patients had a bronchospasm or laryngospasm during awakening. Forty-five patients (24.1%) had complex aneurysms or a history of subarachnoid hemorrhage. Thirty-three of them (73.3%) required orotracheal intubation compared to 24 of the 142 (16.9%) with non-complex aneurysms. Two patients in each group died during early postoperative recovery. Two in each group also had intraoperative bleeding. A post-hoc analysis showed that orotracheal intubation was used in 55 patients (44%) in 2010 through 2014 and 2 (3.2%) in 2015 through 2018, parallel to a trend toward less invasive blood pressure monitoring from the earlier to the later period from 34 (27.2%) cases to 5 (8.2%).ConclusionSupraglottic device, like other less invasiveness protocols, can be considered a feasible alternative airway management approach in selected patients proposed for endovascular treatment of unruptured intracranial aneurisms.
| S-EPMC9373688 | biostudies-literature
Project description:BACKGROUND:Clopidogrel is routinely used to decrease ischemic complications during neurointerventional procedures. However, the efficacy may be limited by antiplatelet resistance. PURPOSE:Our aim was to analyze the efficacy of prasugrel compared with clopidogrel in the cerebrovascular field. DATA SOURCES:A systematic search of 2 large databases was performed for studies published from 2000 to 2018. STUDY SELECTION:According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting treatment-related outcomes of patients undergoing neurointerventional procedures under prasugrel, and studies comparing prasugrel and clopidogrel. DATA ANALYSIS:Random-effects meta-analysis was used to pool the overall rate of complications, ischemic and hemorrhagic events, and influence of the dose of prasugrel. DATA SYNTHESIS:In the 7 included studies, 682 and 672 unruptured intracranial aneurysms were treated under prasugrel (cases) and clopidogrel (controls), respectively. Low-dose (20 mg/5 mg; loading and maintenance doses) prasugrel compared with the standard dose of clopidogrel (300 mg/75 mg) showed a significant reduction in the complication rate (OR = 0.36; 95% CI, 0.17-74, P = .006; I2 = 0%). Overall, the ischemic complication rate was significantly higher in the clopidogrel group (40/672 = 6%; 95% CI, 3%-13%; I2 = 83% versus 16/682 = 2%; 95% CI, 1%-5%; I2 = 73%; P = .03). Low and high loading doses of prasugrel were associated with 0.6% (5/535; 95% CI, 0.1%-1.6%; I2 = 0%) and 9.3% (13/147; 95% CI, 0.2%-18%; I2 = 60%) intraperiprocedural hemorrhages, respectively (P = .001), whereas low and high maintenance doses of prasugrel were associated with 0% (0/433) and 0.9% (2/249; 95% CI, 0.3%-2%; I2 = 0%) delayed hemorrhagic events, respectively (P = .001). LIMITATIONS:Retrospective series and heterogeneous endovascular treatments were limitations. CONCLUSIONS:In our study, low-dose prasugrel compared with clopidogrel premedication was associated with an effective reduction of the ischemic events with an acceptable rate of hemorrhagic complications.
| S-EPMC7048523 | biostudies-literature
Project description:The cost difference between the two treatment options (surgical clipping and endovascular therapy) for unruptured cerebral aneurysms remains an issue of debate. We investigated the association between treatment method for unruptured cerebral aneurysms and Medicare expenditures in elderly patients.We performed a cohort study of 100% Medicare fee-for-service claims data for elderly patients who underwent treatment for unruptured cerebral aneurysms from 2007 to 2012. In order to control for measured confounding we used multivariable regression analysis with mixed effects to account for clustering at the Hospital Referral Region (HRR) level. An instrumental variable (regional rates of endovascular treatment) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method.During the study period 8705 patients underwent treatment for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular treatment. The median total Medicare expenditures in the first year after the admission for the procedure were $46?800 (IQR $31?000-$74?400) for surgical clipping and $48?100 (IQR $34?500-$73?900) for endovascular therapy. When we adjusted for unmeasured confounders, using an instrumental variable analysis, clipping was associated with increased 7-day Medicare expenditures by $3527 (95% CI $972 to $5736) and increased 1-year Medicare expenditures by $15?984 (95% CI $9017 to $22?951).In a cohort of Medicare patients, after controlling for unmeasured confounding, we demonstrated that surgical clipping of unruptured cerebral aneurysms was associated with increased 1-year expenditures compared with endovascular treatment.
| S-EPMC5035560 | biostudies-literature
Project description:OBJECTIVE The impact of combined practices on the outcomes of unruptured cerebral aneurysm coiling remains an issue of debate. The authors investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm coiling. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent endovascular coiling for unruptured cerebral aneurysms between 2007 and 2012. To control for confounding, the authors used propensity score conditioning, with mixed effects to account for clustering at the hospital referral region level. RESULTS During the study period, there were 11,716 patients who underwent endovascular coiling for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 1186 (10.1%) underwent treatment performed by hybrid neurosurgeons, and 10,530 (89.9%) by proceduralists who performed only endovascular coiling. Multivariable regression analysis with propensity score adjustment demonstrated a lack of association of combined practice with 1-year postoperative mortality (OR 0.84; 95% CI 0.58-1.23), discharge to rehabilitation (OR 1.0; 95% CI 0.66-1.51), 30-day readmission rate (OR 1.07; 95% CI 0.83-1.38), and length of stay (adjusted difference, 0.41; 95% CI -0.26 to 1.09). Higher procedural volume was independently associated with improved outcomes. CONCLUSIONS In a cohort of Medicare patients, the authors did not demonstrate a difference in mortality, discharge to rehabilitation, readmission rate, and LOS between hybrid neurosurgeons and proceduralists performing only endovascular coiling.
| S-EPMC5442388 | biostudies-literature
Project description:Giant serpentine aneurysms are fusiform partially thrombosed aneurysms with a separate outflow tract to normal distal cerebral vessels. Three patients with giant serpentine aneurysms of the anterior and middle cerebral arteries were treated with endovascular occlusion of the aneurysmal lumen with coils or glue after balloon test occlusion of the involved vessel. In all 3 patients, leptomeningeal collateral circulation was sufficient to prevent distal ischemia.
| S-EPMC8119165 | biostudies-literature
Project description:Purpose The intrasaccular flow disruptor Woven EndoBridge (WEB) device is developed for the treatment of wide-necked aneurysms without supportive devices. We used the WEB as primary treatment for unruptured aneurysms suitable for the device, regardless of neck size. Methods Between February 2015 and June 2017, 59 aneurysms in 51 patients were selectively treated with the WEB. There were 15 men and 36 women with a mean age of 59 years. Mean aneurysm size was 7.0?mm (range 3-22?mm). Of 59 aneurysms, 45 (76%) had a wide neck defined as ?4?mm or dome-neck ratio ?1.5. No stents or supporting balloons were used. Results Initial WEB position was judged good in all 59 unruptured aneurysms. One patient with a basilar tip aneurysm had a late thrombotic posterior cerebral artery occlusion by protrusion of the WEB over the artery. There were no procedural ruptures. Overall complication rate was 2.0% (1 of 51, 95% CI 0.01-11.3%). Imaging follow-up was available in 55 of 59 aneurysms (93%). At 3 months, 41 of 57 aneurysms (72%) were completely occluded, 12 (21%) had a neck remnant and 4 (7%) were incompletely occluded. Conclusion WEB treatment is safe and effective in selected unruptured aneurysms suitable for the device, regardless of neck size or location. There was no need for supportive devices. Three-quarters of all unruptured small aneurysms could be treated with the WEB. In our opinion, the WEB is a valuable alternative to coils, especially in wide-necked aneurysms.
| S-EPMC6116134 | biostudies-literature
Project description:Background and purposeThe purpose of this study was to report our experience with endovascular treatment of 14 patients with symptomatic intradural vertebral dissecting aneurysms.Materials and methodsBetween January 2000 and January 2006, 14 patients with symptomatic intradural dissecting vertebral aneurysms were treated. A total of 756 (568 ruptured, 188 unruptured) endovascular treated aneurysms (incidence, 1.9%) were treated during this period. There were 7 female and 7 male patients with a mean age of 48 years (age range, 10-64 years). Thirteen patients (93%) presented with subarachnoid hemorrhage (SAH) and 1 (7%) presented with acute symptoms of mass effect on the brain stem.ResultsTreatment consisted of coil occlusion of the dissected arterial segment including the aneurysm (internal coil trapping) in 13 of 14 patients and stent placement over the aneurysm as the only therapy in 1 patient. All aneurysms and occluded arterial segments remained occluded on follow-up imaging at 6 to 13 months, and none of the patients had infarctions in the medulla or territory of the posterior inferior cerebellar artery. Clinical outcome was excellent in 11 patients; 3 had cognitive impairment after SAH but were independent in daily activities. There were no episodes of recurrent hemorrhage.ConclusionIntradural vertebral dissecting aneurysms presenting with SAH should be treated promptly because of the high risk of recurrent hemorrhage. In our experience, trapping of the dissected segment with coils was straightforward, could be done in most patients, and was effective in preventing rebleeding. In our opinion, only in exceptional circumstances are more sophisticated techniques aimed at preservation of the parent artery necessary.
| S-EPMC8119076 | biostudies-literature
Project description:ImportanceThe risk of procedural clinical complications and the case-fatality rate (CFR) from preventive treatment of unruptured intracranial aneurysms varies between studies and may depend on treatment modality and risk factors.ObjectiveTo assess current procedural clinical 30-day complications and the CFR from endovascular treatment (EVT) and neurosurgical treatment (NST) of unruptured intracranial aneurysms and risk factors of clinical complications.Data sourcesWe searched PubMed, Excerpta Medica Database, and the Cochrane Database for studies published between January 1, 2011, and January 1, 2017.Study selectionStudies reporting on clinical complications, the CFR, and risk factors, including 50 patients or more undergoing EVT or NST for saccular unruptured intracranial aneurysms after January 1, 2000, were eligible.Data extraction and synthesisPer treatment modality, we analyzed clinical complication risk and the CFR with mixed-effects logistic regression models for dichotomous data. For studies reporting data on complication risk factors, we obtained risk ratios (RRs) or odds ratios (ORs) with 95% CIs and pooled risk estimates with weighted random-effects models.Main outcomes and measuresClinical complications within 30 days and the CFR.ResultsWe included 114 studies (106 433 patients with 108 263 aneurysms). For EVT (74 studies), the pooled clinical complication risk was 4.96% (95% CI, 4.00%-6.12%), and the CFR was 0.30% (95% CI, 0.20%-0.40%). Factors associated with complications from EVT were female sex (pooled OR, 1.06 [95% CI, 1.01-1.11]), diabetes (OR, 1.81 [95% CI, 1.05-3.13]), hyperlipidemia (OR, 1.76 [95% CI, 1.3-2.37]), cardiac comorbidity (OR, 2.27 [95% CI, 1.53-3.37]), wide aneurysm neck (>4 mm or dome-to-neck ratio >1.5; OR, 1.71 [95% CI, 1.38-2.11]), posterior circulation aneurysm (OR, 1.42 [95% CI, 1.15-1.74]), stent-assisted coiling (OR, 1.82 [95% CI, 1.16-2.85]), and stenting (OR, 3.43 [95% CI, 1.45-8.09]). For NST (54 studies), the pooled complication risk was 8.34% (95% CI, 6.25%-11.10%) and the CFR was 0.10% (95% CI, 0.00%-0.20%). Factors associated with complications from NST were age (OR per year increase, 1.02 [95% CI, 1.01-1.02]), female sex (OR, 0.43 [95% CI, 0.32-0.85]), coagulopathy (OR, 2.14 [95% CI, 1.13-4.06]), use of anticoagulation (OR, 6.36 [95% CI, 2.55-15.85]), smoking (OR, 1.95 [95% CI, 1.36-2.79]), hypertension (OR, 1.45 [95% CI, 1.03-2.03]), diabetes (OR, 2.38 [95% CI, 1.54-3.67]), congestive heart failure (OR, 2.71 [95% CI, 1.57-4.69]), posterior aneurysm location (OR, 7.25 [95% CI, 3.70-14.20]), and aneurysm calcification (OR, 2.89 [95% CI, 1.35-6.18]).Conclusions and relevanceThis study identifies risk factors for procedural complications. Large data sets with individual patient data are needed to develop and validate prediction scores for absolute complication risks and CFRs from EVT and NST modalities.
| S-EPMC6439725 | biostudies-literature
Project description:Abstract Celiac artery (CA) occlusion or stenosis is identified in up to almost half of all patients undergoing abdominal angiography, and the resulting increased collateral blood flow from the superior mesenteric artery to the pancreaticoduodenal artery (PDA) may cause PDA aneurysms (PDAAs). PDAAs are rare but could be fatal if they rupture. However, treatment of the PDAA could block this important collateral blood flow pathway, leading to ischemic organ damage. Treatment of such aneurysms is therefore difficult, especially in patients with multiple PDAAs. Successful treatment of PDAAs requires establishing blood flow in the CA region and selecting which aneurysm(s) to treat. We present four patients who underwent surgery for unruptured PDAAs caused by CA obstruction. Blood flow in the CA region was established by bypassing the splenic artery and by anastomosing it either directly to the left renal artery (n = 1) or to the abdominal aorta using a graft (saphenous vein: n = 1; artificial vessel: n = 2). Three patients had multiple PDAAs: all PDAAs were treated in one patient with PDAAs of similar size and shape, but only the largest PDAA with the highest risk of rupture was treated in the other two patients to simplify the procedure. The median observation period was 19.5 months (range: 11‐28 months), and all patients were alive without recurrence at the time of writing. Surgical treatment including splenic artery bypass may thus be a viable option for treating patients with unruptured PDAAs. Since celiac artery occlusion represents a common attributable aetiology for these aneurysms, restoration of blood flow to the regions supplied by the celiac artery should also be taken into account when designing a treatment plan. Here, we present 4 cases of PDA aneurysms coexisting with coeliac artery occlusion, all of which were managed with bypass surgery using the splenic artery. Furthermore, in this study, we showed that preserving either arcade of the PDA without treating a small aneurysm may provide a secondary pathway and avoid complications in case of bypass problems.
| S-EPMC9831908 | biostudies-literature