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 | 2013 Nov-Dec
REPOSITORIES: biostudies-literature
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Are routine intensive care admissions needed after endovascular treatment of unruptured aneurysms?
Burrows A M AM Rabinstein A A AA Cloft H J HJ Kallmes D F DF Lanzino G G
AJNR. American journal of neuroradiology 20130606 11
<h4>Summary</h4>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 perio ...[more]
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Project description:ObjectiveMultiple studies suggest routine post-operative intensive care unit (ICU) stays after endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is unnecessary, though rates of ICU utilization nationwide are unknown. We aim to evaluate rates and characteristics of ICU utilization in patients undergoing elective endovascular repair of UIAs.MethodsThis is a retrospective cohort study utilizing a nationwide private-payer database in the United States to evaluate the ICU utilization in patients undergoing elective endovascular repair of UIAs between 2005 and 2019. Demographics and pre-operative comorbidities as well as post-procedural complications and discharge status were compared. An analysis of charges and costs was also performed.ResultsAmong 6218 patients who underwent elective EVT of a UIA, 4890 (78.6%) were admitted to the ICU post-operatively. There were no differences in age, sex, or Charlson comorbidity scores in patients admitted to the ICU post-operatively compared to those admitted elsewhere. ICU utilization was more common in urban locations compared to rural. 12.7% of patients had ICU-specific needs sufficient to be billed by a critical care provider. Total provider costs were significantly higher in patients utilizing the ICU post-operatively, even among uncomplicated patients with routine discharges.ConclusionMost patients undergoing elective endovascular UIA repair in the United States are admitted to the ICU postoperatively. Only 12.7% have ICU needs, and these patients are predictable from pre-operative characteristics or peri-operative complications. Reducing ICU use in this subgroup of patients may be an important target to improve healthcare value in this patient population.
| S-EPMC11569808 | biostudies-literature
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:BackgroundThe management of unruptured intracranial aneurysm (UIA) remains controversial. Recently, machine learning has been widely applied in the field of medicine. This study developed predictive models using machine learning to investigate periprocedural complications associated with endovascular procedures for UIA.MethodsWe enrolled patients with solitary UIA who underwent endovascular procedures. Periprocedural complications were defined as neurological adverse events resulting from endovascular procedures. We incorporated three machine learning algorithms into our prediction models: artificial neural networks (ANN), random forest (RF), and logistic regression (LR). The Shapley Additive Explanations (SHAP) approach and feature importance analysis were used to identify and prioritize significant features associated with periprocedural complications.ResultsIn total, 443 patients were included. Forty-eight (10.83%) procedure-related complications occurred. In the testing set, the ANN model produced the largest value (0.761) for area under the curve (AUC). The RF model also achieved an acceptable AUC value of 0.735, while the AUC value of the LR model was 0.668. SHAP and feature importance analysis identified distal aneurysm, aneurysm size and treatment modality as most significant features for the prediction of periprocedural complications following endovascular treatment for UIA.ConclusionPeriprocedural complications after endovascular treatment for UIA are not negligible. Prediction of periprocedural complications via machine learning is feasible and effective. Machine learning can serve as a promising tool in the decision-making process for UIA treatment.
| S-EPMC9596813 | 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:BackgroundCurrently, endovascular treatment of intracranial aneurysms (ICAs) is limited by low complete occlusion rates. The advent of novel endovascular technology has expanded the applicability of endovascular therapy; however, the superiority of novel embolic devices over the traditional Guglielmi detachable coils (GDCs) is still debated. We performed a systematic review of literature that reported Raymond-Roy occlusion classification (RROC) rates of modern endovascular devices to determine their immediate and follow-up occlusion effectiveness for the treatment of unruptured saccular ICAs.MethodsA search was conducted using electronic databases (PUBMED, Cochrane, ClinicalTrials.gov, Web of Science). We retrieved studies published between 2000-2022 reporting immediate and follow-up RROC rates of subjects treated with different endovascular ICA therapies. We extracted demographic information of the treated patients and their reported angiographic RROC rates.ResultsA total of 80 studies from 15 countries were included for data extraction. RROC rates determined from angiogram were obtained for 21,331 patients (72.5% females, pooled mean age: 58.2 (95% CI: 56.8-59.6), harboring 22,791 aneurysms. The most frequent aneurysm locations were the internal carotid artery (46.4%, 95% CI: 41.9%-50.9%), the anterior communicating artery (26.4%, 95% CI: 22.5%-30.8%), the middle cerebral artery (24.5%, 95% CI:19.2%-30.8%) and the basilar tip (14.4%, 95% CI:11.3%-18.3%). The complete occlusion probability (RROC-I) was analyzed for GDCs, the Woven EndoBridge (WEB), and flow diverters. The RROC-I rate was the highest in balloon-assisted coiling (73.9%, 95% CI: 65.0%-81.2%) and the lowest in the WEB (27.8%, 95% CI:13.2%-49.2%). The follow-up RROC-I probability was homogenous in all analyzed devices.ConclusionsWe observed that the coil-based endovascular therapy provides acceptable rates of complete occlusion, and these rates are improved in balloon-assisted coils. Out of the analyzed devices, the WEB exhibited the shortest time to achieve >90% probability of follow-up complete occlusion (~18 months). Overall, the GDCs remain the gold standard for endovascular treatment of unruptured saccular aneurysms.
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Project description:Background and purposeDuring the past several years, the number of unruptured aneurysms treated with endovascular techniques has increased. Traditionally, coil embolization was the treatment of choice for these lesions; however, recently flow diversion has become a viable, and in some cases superior, treatment option. The current single-center study presents results and trends of endovascular treatment with flow diversion and coil embolization in an unselected group of patients with unruptured intracranial aneurysms in a "real world" setting during the flow-diverter era.Materials and methodsThree hundred ten patients with 318 treated unruptured aneurysms from June 2009 to May 2015 were included. Patient demographics, clinical characteristics, aneurysm/treatment characteristics, and outcomes were collected prospectively. We studied the following: intensive care unit admission/reasons, perioperative and mid-/long-term complications, target aneurysm rupture, retreatment/recurrence rates, and long-term neurologic outcome using the mRS.ResultsThe flow-diverter group had a larger mean aneurysm size (12.3 ± 8.6 mm versus 8.7 ± 6.3 mm, P < .0001). There were no significant differences in the immediate (P = .43) and mid-/long-term complication rates (P = .54) between groups. Periprocedural neurologic morbidity and mortality rates were 2.1% and 0.5% in the coiling group and 2.5% and 1.6% in the flow-diverter group. Patients with coiling were more likely to be retreated than those with flow diversion (14.8% versus 5.7%, P = .009). Worsening of the mRS due to the target aneurysm was noted in only 3.2% of patients.ConclusionsThe endovascular treatment of unruptured aneurysms can be performed with very low rates of neurologic complications. Both flow-diverter and coil therapy were safe and effective.
| S-EPMC7963541 | 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:BackgroundThe 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.MethodsWe 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.ResultsDuring 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).ConclusionsIn 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: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