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Endovascular options for the treatment of basilar apex aneurysms (BAAs) are heterogeneous, and evidence is limited to retrospective cohorts and case series. We seek to evaluate the efficacy and complications associated with various endovascular treatment methods of BAAs. Systematic review of PubMed, Embase, and Web of Science adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Retrospective and prospective studies evaluating endovascular treatment of BAAs between January 2010 and July 2024 were included. Relevant information including occlusion rates, aneurysm recurrence, retreatment rates, and complications were subjected to meta-analysis. Fifteen studies with 1049 BAAs were included. The median aneurysm diameter was 8.5 mm (range, 4.6–19.75), with a median follow-up of 33.7 months (range, 6.0–117.6). Residual aneurysm filling occurred in 24% after primary coiling (95% CI = 0.16–0.32), 25% after single stent-assisted coiling (s-SAC; 95% CI = 0.04–0.46), 25% after Y-stents (95% CI = 0.12–0.37), and 23% after flow diverter stent (FDS; 95% CI = 0.11–0.35). Recurrence rates were high for primary coiling (27%, 95% CI = 0.18–0.36) and s-SAC (19%, 95% CI = 0.13–0.26), but significantly lower for Y-stents (9%, 95% CI = 0.03–0.15) and FDS (4%, 95% CI = −0.04–0.11). Retreatment rates were 19% for primary coiling (95% CI = 0.12–0.26), 17% for s-SAC (95% CI = 0.07–0.27), 5% for Y-stents (95% CI = −0.03–0.12), and 13% for FDS (95% CI = −0.01–0.27). Meta-regression indicated larger aneurysms had higher complication rates (P = 0.02). Thromboembolic events were most frequent with FDS and Y-stents(12%). Occlusion rates were similar across treatments, but recurrence rates were significantly lower after Y-stents and FDS compared to primary coiling, although they carried a higher number of thromboembolic complications. [ABSTRACT FROM AUTHOR]

For symptomatic stenosis in the middle cerebral artery (MCA), intracranial angioplasty and stenting are frequently employed. However, limited data exist regarding their long-term impact. Our study demonstrates the long-term advantages in preventing ischemic events through a 5-year follow-up period. A set of 41 individuals with symptomatic stenosis in the MCA who underwent angioplasty or stenting procedures between October 2004 and April 2018 at various hospitals in Southwest China were prospectively enrolled in the study. The rates of successful revascularization, complications, imaging observations, and clinical outcomes were systematically assessed. A total of 41 individuals successfully underwent stenting, respectively. After stenting, the extent of stenosis was decreased from 71.8% (56–87.8%) to 24.9% (0–45%). The mean follow-up period is 36.9 ± 13.68 months (range, 11–67 months). There was no deterioration of neurological function or a new ischemic event. A DSA or CT angiography was conducted after the procedure and demonstrated no in-stent restenosis. No patient experienced restenosis below 50% during the mean follow-up period. The morbidity and mortality rates of the case series were 7.3% and 2.4%, respectively. In the treatment of symptomatic MCA atherosclerotic stenoses, intracranial angioplasty and stenting are demonstrated to be technically feasible and safe. Its early and long-term efficacy on ischemic event prevention is acceptable, with a reduced level of restenosis, although the representative sample is tiny. [ABSTRACT FROM AUTHOR]

A four-year-old spayed female Shiba Inu dog weighing 6.1 kg presented with ascites. Cor triatriatum dexter (CTD) without any other concurrent cardiovascular anomalies was diagnosed using echocardiography. The ostium of the abnormal membrane dividing the right atrium into two abnormal chambers was surgically excised under cardiopulmonary bypass. All clinical abnormalities were resolved after surgery. However, seven months later, ascites and CTD recurred. A balloon-expandable stent was placed at the site of recurrence, which improved caudal venous return to the right ventricle. After the second procedure, ascites were resolved, and the dog remained asymptomatic for 18 months without complications. There are previous reports of successful surgical resection of the CTD and of stenting in recurrent CTD following balloon dilation in dogs. However, to the authors' knowledge, no previous reports have described recurrent CTD in dogs after surgical resection of the CTD. In this case, as with recurrent CTD following balloon dilation, stent placement at the site of the CTD can be a viable treatment option when the abnormal membrane recurs. [ABSTRACT FROM AUTHOR]

The long term benefit of carotid angioplasty and stenting (CAS) can be reduced by recurrent stroke related to in stent re-stenosis (ISR). An individualised predictive tool is needed to identify ISR events. A nomogram for individual risk assessment of ISR ≥ 70% after CAS is proposed. A national observational, prospective, multicentre registry was conducted between January 2015 and December 2020. Cohorts of patients with symptomatic or asymptomatic severe carotid stenosis who underwent CAS with a follow up of at least one year after CAS were included. Duplex ultrasound was used to assess in stent re-stenosis. Pre-operative factors were compared between the non-ISR and ISR groups. Kaplan–Meier and Cox regression were used for variable selection. The nomogram was formulated and validated by concordance indices and calibration curves. An in stent re-stenosis risk table was generated for risk stratification. A total of 354 patients were included in the analysis. The ISR rate of ≥ 70% was 7.6% (n = 27). Peripheral arterial disease (hazard ratio [HR] 3.18, 95% confidence interval [CI] 1.23 – 8.24, p =.017), anterior communicating artery absence (HR 3.38, 95% CI 1.27 – 8.94, p =.016), diabetes mellitus (HR 3.34, 95% CI 1.21 – 9.26, p =.020), female sex (HR 2.99, 95% CI 1.04 – 8.60, p =.041), and pre-procedure pathological ultrasound vasoreactivity (HR 3.87, 95% CI 1.43 –10.50, p =.008), as independent risk factors for ISR of ≥ 70%, were included in the nomogram. The concordance index at 12 and 24 months was 0.83. In low risk groups, ISR of ≥ 70% occurred in 4.8% of patients during follow up compared with 56.2% of patients in the high risk groups (p <.001). The nomogram and risk evaluation score have good predictive ability for ISR. They can be used as practical clinical tools for individualised risk assessment. [ABSTRACT FROM AUTHOR]

Spontaneous carotid artery dissections (sCADs) are the common cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 patients with sCAD and proposed a new classification for sCAD with prognostic and therapeutic significance. This is a retrospective review of prospectively collected data from June 2018 to June 2023 of patients with sCAD treated at a large tertiary academic institution in an urban city in China. Based on imaging results, we categorize sCAD into four types: type Ⅰ, intramural hematoma or dissection with <70% luminal narrowing; type Ⅱ, intramural hematoma or dissection with ≥70% luminal narrowing; type Ⅲ, dissecting aneurysm; type ⅣA, extracranial carotid artery occlusion; and type ⅣB, tandem occlusion. We compared the clinical data and prognostic outcomes among various types of sCADs. A total of 179 patients and 197 dissected arteries met the inclusion criteria. The mean age of the 179 patients with sCAD was 49.5 years, 78% were male, and 18 patients (10%) had bilateral sCAD. According to our classification, there were 56 type Ⅰ (28.4%), 50 type Ⅱ (25.4%), 60 type Ⅲ (30.5%), and 31 type Ⅳ (15.7%) dissections. During a mean hospitalization length of 11.4 ± 47.0 days, there were nine recurrent strokes (4.6%) after medical treatment, two type Ⅲ dissections (1.0%), seven type Ⅳ dissections (3.6%), all ipsilateral, and one death. Overall, there were seven (3.6%, 1 type Ⅰ dissection, 3 type Ⅱ dissections, 2 type Ⅲ dissections, and 1 type Ⅳ dissection) recurrent strokes and three (1.5%, all type Ⅲ dissections) recurrent transient ischemic attacks in patients treated with just medical therapy during the follow-up period, all ipsilateral, with a mean follow-up of 26 months (range, 3-59 months). These patients did not undergo further intervention due to the high difficulty associated with endovascular treatment (EVT) or the mild nature of recurrent cerebral ischemic symptoms. Twenty-nine type I dissections (51.8%) were completely recanalized after antithrombotic therapy. A total of 19 type II dissections (38%) and 44 type III dissections (73%) received EVT for persistent flow-limited dissections, enlargement of dissecting aneurysms, or aggravation of neurological symptoms despite antithrombotic therapy. Type Ⅳ dissections are more likely to lead to the occurrence of ischemic stroke and presented with more severe symptoms. Eight type IVB dissections (33%) received acute phase intervention due to distal thromboembolism or aggravation of neurological symptoms after medical treatment. In terms of cerebral ischemic events and mortality, there were no statistically significant differences among the four types of sCAD (all P >.05). Favorable outcome was achieved in 168 patients (93.9%). This study proposed a novel and more comprehensive classification method and the modern management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA dissections. Urgent procedure with neurovascular intervention is necessary for some type IVB dissections. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcomes should undergo further research. [ABSTRACT FROM AUTHOR]

The therapeutic possibilities of endoscopy have rapidly increased in the last decades and now allow organ-sparing treatment of early upper gastrointestinal malignancy as well as an increasing number of options for symptom palliation. This review contains an overview of the interventional endoscopic procedures in upper gastrointestinal malignancies. It describes endoscopic treatment of early oesophageal and gastric cancers, and the palliative options in managing dysphagia and gastric outlet obstruction. It also provides an overview of the therapeutic possibilities of biliary endoscopy, such as retrograde stenting and radiofrequency biliary ablation. Endoscopic ultrasound-guided therapeutic options are discussed, including biliary drainage, gastrojejunostomy and coeliac axis block. To aid in clinical decision making, the procedures are described in the context of their indication, efficacy, risks and limitations. • Endoscopy now offers curative treatments for early oesophageal and gastric cancer. • Interventional endoscopy can offer effective symptom palliation for dysphagia, pain and jaundice. • Duodenal stents and EUS-guided interventions provide effective palliation in gastric obstruction. [ABSTRACT FROM AUTHOR]

Most surgeons employ an endovascular-first approach to the treatment of peripheral arterial disease (PAD), but controversy remains regarding the ideal interventions for the management of isolated popliteal artery disease (IPAD). Indeed, there are a paucity of data that compare outcomes of popliteal stents vs other peripheral vascular interventions (PVIs). The goal of this study was to evaluate outcomes of PVIs in IPAD. The Vascular Study Group of New England database was queried for all IPAD PVIs performed for atherosclerotic occlusive disease from 2010 to 2021. Those with at least 1 year of follow-up data available were included for analysis. The primary endpoint was 1-year freedom from a composite target lesion (TL) treatment failure that included restenosis >50% on duplex, reintervention, or ipsilateral major amputation. We included 689 procedures performed on 634 patients. Of these, 250 (36.3%) were treated with plain balloons (POBA), 215 (31.2%) had stents, 170 (24.7%) had special balloons (drug-coated, cutting, or lithotripsy), and 54 (7.8%) atherectomies were performed. Stent placement was associated with lower freedom from TL treatment failure (72.6%) than special balloon (81.2%; P =.048) and atherectomy (88.9%; P =.012), but not POBA (76.8%; P =.293). On multivariable logistic regression, stents (odds ratio, 0.637; P =.021) and preoperative P2Y12 inhibitor therapy (odds ratio, 0.683; P =.048) were both associated with lower freedom from intervention failure. Popliteal stent placement is associated with a higher rate of TL treatment failure at 1 year when compared with other PVIs including special balloon angioplasty and atherectomy, but not POBA, and should therefore be avoided in favor of special balloons or atherectomy whenever feasible. [ABSTRACT FROM AUTHOR]

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed. [ABSTRACT FROM AUTHOR]

• Postoperative new sNCLI assessed by DWI was detected in 28.2% of patients after CAS. • A higher PCT level is identified as an independent risk factor for the development of sNCLI in patients treated with endovascular intervention for carotid artery stenosis. • Other independent risk factors for the development of sNCLI include advanced age and the absence of embolism protection device use. Silent new cerebral ischemic lesions (sNCIL) are a common complication of carotid artery stenting (CAS) that can lead to an increase in morbidity and mortality. We aimed to evaluate the impact of hematological parameters on sNCIL in patients undergoing CAS. We retrospectively evaluated 103 patients who underwent CAS, with a mean age of 70.5 ± 6.7 years, and 31 (20.1 %) of whom were female. Stents were placed for internal carotid artery revascularization. The presence of new hyperintense lesions on diffusion-weighted imaging (DWI) without neurological symptoms was considered as sNCIL in cases without apparent neurological findings. Patients were categorized into two groups based on DWI results: positive (29) and negative (74). In the study population, sNCIL was observed in 29 patients (28.2 %). The DWI-positive group exhibited significantly higher Plateletcrit (PCT) levels, advanced age, and a lack of embolic protection device usage compared to the DWI-negative group. The Receiver Operating Characteristic (ROC) analysis identified a PCT value of 0.26 as the optimal threshold, detecting the development of sNCIL with a sensitivity of 75.9 % and specificity of 59.1 % (AUC: 0.700; 95 % CI: 0.594–0.806, p = 0.002). To be determined by a simple blood parameter, PCT can predict the risk of sNCIL before CAS and holds clinical value in the treatment of patients with carotid artery stenosis. [ABSTRACT FROM AUTHOR]

Although numerous case series and meta-analyses have shown the efficacy of venous sinus stenting (VSS) in the treatment of idiopathic intracranial hypertension and idiopathic intracranial hypertension–associated pulsatile tinnitus, there remain numerous challenges to be resolved. There is no widespread agreement on candidacy; pressure gradient and failed medical treatment are common indications, but not all clinicians require medical refractoriness as a criterion. Venous manometry, venography, and cerebral angiography are essential tools for patient assessment, but again disagreements exist regarding the best, or most appropriate, diagnostic imaging choice. Challenges with the VSS technique also exist, such as stent choice and deployment. There are considerations regarding postprocedural balloon angioplasty and pharmacologic treatment, but there is insufficient evidence to formalize postoperative decision making. Although complications of VSS are relatively rare, they include in-stent stenosis, hemorrhage, and subdural hematoma, and the learning curve for VSS presents specific challenges in navigating venous anatomy, emphasizing the need for wider availability of high-quality training. Recurrence of symptoms, particularly stent-adjacent stenosis, poses challenges, and although restenting and cerebrospinal fluid–diverting procedures are options, there is a need for clearer criteria for retreatment strategies. Despite these challenges, when comparing VSS with traditional cerebrospinal fluid–diverting procedures, VSS emerges as a favorable option, with strong clinical outcomes, lower complication rates, and cost-effectiveness. Further research is necessary to refine techniques and indications and address specific aspects of VSS to overcome these challenges. [ABSTRACT FROM AUTHOR]

Venous sinus stenosis has garnered increasing academic attention as a potential etiology of idiopathic intracranial hypertension (IIH) and pulsatile tinnitus (PT). The complex anatomy of the cerebral venous sinuses and veins plays a crucial role in the pathophysiology of these conditions. Venous sinus stenosis, often found in the superior sagittal or transverse sinus, can lead to elevated intracranial pressure (ICP) and characteristic IIH symptoms. Stenosis, variations in dural venous anatomy, and flow dominance patterns contribute to aberrant flow and subsequent PT. Accurate imaging plays a vital role in diagnosis, and magnetic resonance (MR) venography is particularly useful for detecting stenosis. Management strategies for IIH and PT focus on treating the underlying disease, weight management, medical interventions, and, in severe cases, surgical or endovascular procedures. Recently, venous sinus stenting has gained interest as a minimally invasive treatment option for IIH and PT. Stenting addresses venous sinus stenosis, breaking the feedback loop between elevated ICP and stenosis, thus reducing ICP and promoting cerebrospinal fluid outflow. The correction and resolution of flow aberrances can also mitigate or resolve PT symptoms. While venous sinus stenting remains an emerging field, initial results are promising. Further research is needed to refine patient selection criteria and evaluate the long-term efficacy of stenting as compared to traditional treatments. [ABSTRACT FROM AUTHOR]

Peripheral arterial stenoses (PAS) are commonly investigated with duplex ultrasound (DUS) and angiography, but these are not functional tests. Fractional flow reserve (FFR), a pressure based index, functionally assesses the ischaemic potential of coronary stenoses, but its utility in PAS is unknown. FFR in the peripheral vasculature in patients with limb ischaemia was investigated. Patients scheduled for angioplasty and or stenting of isolated iliac and superficial femoral artery stenoses were recruited. Resting trans-lesional pressure gradient (P d / P a) and FFR were measured after adenosine provoked hyperaemia using an intra-arterial 0.014 inch flow and pressure sensing wire (ComboWire XT, Philips). Prior to revascularisation, exercise ABPI (eABPI) and DUS derived peak systolic velocity ratio (PSVR) of the index lesion were determined. Calf muscle oxygenation was measured using blood oxygenation level dependent cardiovascular magnetic resonance prior to and after revascularisation. Forty-one patients (32, 78%, male, mean age 65 ± 11 years) with 61 stenoses (iliac 32; femoral 29) were studied. For lesions < 80% stenosis, resting P d / P a was not influenced by the degree of stenosis (p =.074); however, FFR was discriminatory, decreasing as the severity of stenosis increased (p =.019). An FFR of < 0.60 was associated with critical limb threatening ischaemia (area under the curve [AUC] 0.87; 95% CI 0.75 – 0.95), in this study performing better than angiographic % stenosis (0.79; 0.63 – 0.89), eABPI (0.72; 0.57 – 0.83), and PSVR (0.65; 0.51 – 0.78). FFR correlated strongly with calf oxygenation (rho, 0.76; p <.001). A greater increase in FFR signalled resolution of symptoms and signs (ΔFFR 0.25 ± 0.15 vs. 0.13 ± 0.09; p =.009) and a post-angioplasty and stenting FFR of > 0.74 predicted successful revascularisation (combined sensitivity and specificity of 95%; AUC 0.98; 0.91 – 1.00). This pilot study demonstrates that FFR can objectively measure the functional significance of PAS that compares favourably with visual and DUS based assessments. Its role as a quality control adjunct that confirms optimal vessel patency after angioplasty and or stenting also merits further investigation. [ABSTRACT FROM AUTHOR]

Stent loss in coronary arteries is a rare complication of coronary intervention. Furthermore, the entanglement of a lost stent with a second previously deployed stent leading to a very complicated scenario has not been reported previously. In this case, we are presenting the first case report of a stent loss due to the entanglement of a stent with the ostial part of the second already deployed side branch stent leading to distortions of the second stent and entrapment. This is also the first case report describing the successful and simultaneous retrieval of both the lost and entangled deployed stents percutaneously using the distal inflating balloon technique. [ABSTRACT FROM AUTHOR]

Chronic mesenteric ischaemia (CMI) treatment focuses on symptom relief and prevention of disease progression. Endovascular repair represents the main treatment modality, while data on the associated antiplatelet regimen are scarce. The aim of this meta-analysis was to assess the early and midterm outcomes of endovascular repair in patients with CMI. Randomised controlled trials and observational studies (1990 – 2022) reporting on early and midterm endovascular repair outcomes in patients with atherosclerotic CMI. The PRISMA guidelines and PICO model were followed. The protocol was registered to PROSPERO (CRD42023401685). Medline, Embase (via Ovid), and Cochrane databases were searched (end date 21 February 2023). The Newcastle–Ottawa Scale was used for risk of bias assessment, and GRADE for evidence quality assessment. Primary outcomes were technical success, 30 day mortality, and symptom relief, assessed using prevalence meta-analysis. The role of dual antiplatelet therapy (DAPT) was investigated using meta-regression analysis. Sixteen retrospective studies (1 224 patients; mean age 69.8 ± 10.6 years; 60.3% female) reporting on 1 368 target vessels (57.8% superior mesenteric arteries) were included. Technical success was 95.0% (95% CI 93 – 97%, p =.28, I 2 19%, low certainty), the 30 day mortality rate was 2.0% (95% CI 2 – 4%, p =.93, I 2 36%, low certainty), and immediate symptom relief was 87.0% (95% CI 80 – 92%, p <.010, I 2 85%, very low certainty). At mean follow up of 28 months, the mortality rate was 15.0% (95% CI 9 – 25%, p =.010, I 2 86%, very low certainty), symptom recurrence 25.0% (95% CI 21 – 31%, p <.010, I 2 68%, very low certainty) and re-intervention rate 26.0% (95% CI 17 – 37%, p <.010, I 2 92%, very low certainty). Single antiplatelet therapy (SAPT) and DAPT performed similarly in the investigated outcomes. Endovascular repair for CMI appears to be safe as first line treatment, with a low peri-operative mortality rate and acceptable immediate symptom relief. During midterm follow up, symptom recurrence and need for re-intervention are not uncommon. SAPT appears to be equal to DAPT in post-operative outcomes. [ABSTRACT FROM AUTHOR]

Celiac artery compression syndrome (CACS) is a disease caused by celiac artery compression by the median arcuate ligament (MAL), resulting in intestinal ischemic symptoms. However, a clear method for the invasive treatment of CACS has not yet been established because of limited treatment indications. In particular, only a few reports of endovascular therapy (EVT) using stents as the initial invasive treatment are available. Here, we report a case where EVT was performed using a stent in the celiac artery, resulting in good outcomes. A 59-year-old male patient presented to our hospital with postprandial abdominal pain and was diagnosed with MAL-induced CACS since the abdominal contrast computed tomography examination showed stenosis of a celiac artery origin. He was aware of the abdominal pain symptoms; therefore, we decided to treat CACS with EVT as an invasive treatment. A bare metal stent was placed in the celiac artery, whose lumen was well dilated using intravascular ultrasound. Consequently, he no longer felt abdominal pain and had good stent patency after 15 months. Minimally invasive EVT may be considered the first-line treatment for CACS. The efficacy of endovascular therapy (EVT) using stents for the invasive treatment of celiac artery compression syndrome (CACS) resulting from the compression of the median arcuate ligament has not yet been established. Specifically, the efficacy of EVT using stents for CACS is unknown. We can safely perform EVT with stent placement using intravascular ultrasound for maintaining long-term patency. Therefore, minimally invasive EVT may be considered the first-line treatment for CACS. [ABSTRACT FROM AUTHOR]

Dual antiplatelet therapy (DAPT) continues to be the preferred medication regimen after the placement of a carotid stent using the transcarotid revascularization (TCAR) technique despite a dearth of quality data. Therefore, this investigation was performed to define the risks associated with antiplatelet choice. We queried all patients who underwent TCAR captured by the Vascular Quality Initiative from September 2016 to June 2022, to determine the association between antiplatelet choice and outcomes. Patients maintained on DAPT were compared with those receiving alternative regimens consisting of single antiplatelet, anticoagulation, or a combination of the two. A 1:1 propensity-score match was performed with respect to baseline comorbidities, functional status, anatomic/physiologic risk, medications, and intraoperative characteristics. In-hospital and 1-year outcomes were compared between the groups. During the study period, 29,802 procedures were included in our study population, with 24,651 (82.7%) receiving DAPT and 5151 (17.3%) receiving an alternative antiplatelet regimen. A propensity-score match with respect to 29 variables generated 4876 unique pairs. Compared with patients on DAPT, in-hospital ipsilateral stroke was significantly higher in patients receiving alternative antiplatelet regimens (1.7% vs 1.1%, odds ratio [95% confidence interval]: 1.54 [1.10-2.16], P =.01), whereas no statistically significant difference was noted with respect to mortality (0.6% vs 0.5%, 1.35 [0.72-2.54], P =.35). A composite of stroke/death was also more likely in patients receiving an alternative regimen (2.4% vs 1.7%, 1.47 [1.12-1.93], P =.01). Immediate stent thrombosis (2.75 [1.16-6.51]) and a nonsignificant trend toward increased return to the operating room were more common in the alternative patients. Conversely, the incidence of perioperative myocardial infarction was lower in the alternative regimen group (0.4% vs 0.7%, 0.53 [0.31-0.90], P =.02). At 1 year after the procedure, we observed an increased risk of mortality (hazard ratio [95% confidence interval]: 1.34 [1.11-1.63], P <.01) but not stroke (0.52 [0.27-0.99], P =.06) in patients treated with an alternative medication regimen. This propensity-score-matched analysis demonstrates an increased risk of in-hospital stroke and 1-year mortality after TCAR in patients treated with an alternative medication regimen instead of DAPT. Further studies are needed to elucidate the drivers of DAPT failure in patients undergoing TCAR to improve outcomes for carotid stenting patients. [ABSTRACT FROM AUTHOR]

The Wingspan stent system was approved as a rescue device for angioplasty of intracranial atherosclerotic disease (ICAD) in 2012. We conducted the government-recommended Japanese Postmarket Surveillance of Percutaneous Transluminal Angioplasty and Wingspan Stenting for Intracranial Atherosclerotic Disease to monitor Wingspan safety and performance. In this open-label, single-arm study at 76 centers in Japan, ICAD subjects were treated with the Wingspan stent between 2014 and 2016. Efficacy end points were successful stent deployment and technical success, defined as stenosis improvement to <50%. Safety end points were ischemic stroke, modified Rankin Scale and National Institutes of Health Stroke Scale scores, adverse events, and mortality. Subjects were considered treated outside of current recommendations if not already receiving antithrombotics or if percutaneous transluminal angioplasty and stenting occurred within 7 days of onset. The safety cohort included 305 subjects (mean age: 68.7 + 9.6; 83.3% male). Four subjects were removed due to being out of contract. Therefore, 301 subjects were included (mean age: 68.7 ± 9.7; 84.1% male). Successful stent placement was 96.7%. Technical success was observed in 86.8% of lesions. At 1 year, the rate of restenosis was 15.7%, ischemic stroke was 3.9%, and any stroke was 7.9%. Functionally independent outcome (modified Rankin Scale: 0–2) was 88.9% and mortality 3.0%. Significantly more serious adverse events occurred in subjects treated outside of current recommendations (17.9%) versus subjects treated per current recommendations (8.8%) (P = 0.045). Endovascular treatment using the Wingspan stent for ICAD is safe and effective in the Japanese population. [ABSTRACT FROM AUTHOR]

We evaluated limb salvage (LS), amputation-free survival (AFS), and target extremity reintervention (TER) after plain old balloon angioplasty (POBA), stenting, and atherectomy for treatment of infrapopliteal disease (IPD) with chronic limb-threatening ischemia (CLTI). All index peripheral vascular interventions for IPD and CLTI were identified from the Vascular Quality Initiative registry. Of the multilevel procedures, the peripheral vascular intervention type was indexed to the infrapopliteal segment. Propensity score matching was used to control for baseline differences between groups. Kaplan-Meier and Cox regression were used to calculate and compare LS and AFS. The 3-year LS for stenting vs POBA was 87.6% vs 81.9% (P =.006) but was not significant on Cox regression analysis (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.56-0.76; P =.08). AFS was superior for stenting vs POBA (78.1% vs 69.5%; P =.001; HR, 0.73; 95% CI, 0.60-0.90; P =.003). LS was similar for POBA and atherectomy (81.9% vs 84.8%; P =.11) and for stenting and atherectomy (87.6% vs 84.8%; P =.23). The LS rate after propensity score matching for POBA vs stenting was 83.4% vs 88.2% (P =.07; HR, 0.71; 95% CI, 0.50-1.017; P =.062). The AFS rate for stenting vs POBA was 78.8% vs 69.4% (P =.005; HR, 0.69; 95% CI, 0.54-0.89; P =.005). No significant differences were found between stenting and atherectomy (P =.21 for atherectomy; and P =.34 for POBA). The need for TER did not differ across the groups but the interval to TER was significantly longer for stenting than for POBA or atherectomy (stenting vs POBA, 12.8 months vs 7.7 months; P =.001; stenting vs atherectomy, 13.5 months vs 6.8 months; P <.001). Stenting and atherectomy had comparable LS and AFS for patients with IPD and CLTI. However, stenting conferred significant benefits for AFS compared with POBA but atherectomy did not. Furthermore, the interval to TER was nearly double for stenting compared with POBA or atherectomy. These factors should be considered when determining the treatment strategy for this challenging anatomic segment. [ABSTRACT FROM AUTHOR]

• Stenting is the simultaneous use of grafting and cutting methods in one action. • The different stem parts as rootstock are important for the success of stenting. • The different stem parts affect phenolic compounds in the biosynthesis of lignin. • Antioxidant enzymes play a key role in graft union and adventitious root formation. • The bottom and middle positions of stem should be used to multiply by stenting. Stenting is a commercial propagation method for roses that combines grafting and cutting in one action and the resulting plantlet is named 'stentling'. Several physiological and biochemical factors can significantly influence graft union healing and adventitious root formation. The effect of rootstock and its cutting-prepared region have not been well studied for successful stenting. We provide a comprehensive overview of the physiological and biochemical aspects of the stenting process, utilizing rootstock positions as the source of variation among treatments. Morphophysiological and biochemical assays were performed to evaluate the effect of three different stem parts (bottom, middle, and top) of 'Natal Briar' as rootstock on graft union healing and adventitious root formation of the rose stentlings. When the rootstock originating from the bottom and middle positions improved the physiological, biochemical, and morphological responses of the stentling, significantly. In this regard, the improved biochemical properties, including total soluble sugars, total phenolic and flavonoid contents, phenylalanine ammonia-lyase, peroxidase and lignin content seem to play a special role in the success of grafting and subsequently the adventitious root formation. Assessing morphophysiological and biochemical parameters paves the way for a better understanding of the mechanism of successful stenting. [ABSTRACT FROM AUTHOR]

The outcomes associated with transcarotid revascularization (TCAR) have proved to be noninferior to the historical results established for carotid endarterectomy (CEA). Therefore, TCAR has been increasingly offered to patients with neck anatomy hostile for traditional CEA. The present investigation was completed to evaluate whether a difference exists for patients undergoing TCAR in de novo anatomy with unviolated surgical planes compared with those undergoing TCAR in necks with hostile anatomy. The demographic data and outcomes were captured at two high-volume TCAR institutions from December 2015 to December 2021 via a query of two parallel, prospectively maintained, carotid intervention databases at these two health institutions. A hostile neck anatomy was defined as a history of previous ipsilateral neck radiation, oncologic dissection, or CEA. Univariate analysis was performed to compare the two cohorts at an α of 0.05. During the inclusion period, the data from 750 TCARs were captured, including 108 procedures in hostile neck anatomy and 642 in de novo necks. No significant differences were found in the baseline comorbidity burden using the Charlson comorbidity index or the indication for revascularization. Intraoperatively, no significant increase in case complexity was observed with respect to those with a hostile neck, except for the operative time, which was 10% longer (69.5 vs 63.4 minutes; P =.01). The flow reversal and fluoroscopic times, blood loss, radiation exposure, and contrast use were identical. Postoperatively, no differences were observed between the hostile and de novo necks with respect to stroke (0.9% vs 2.5%; P =.49), myocardial infarction (0.9% vs 0.2%; P =.27), and death (0% vs 1.5%; P =.37). Additionally, hematoma formation and the need for reintervention did not seem to vary between the two groups. Similarly, no differences in the two cohorts were noted during follow-up. According to the findings from our large, dual-institutional series, the performance of TCAR in surgical fields traditionally hostile for CEA was not associated with increased intraoperative complexity or postoperative morbidity. [Display omitted] [ABSTRACT FROM AUTHOR]

In the present report, we have detailed the results derived from the adoption of transcarotid artery revascularization (TCAR) at a large health system based in the United States. A retrospective review was performed of a prospectively maintained database capturing all carotid stents deployed using the ENROUTE neuroprotection device (Silk Road Medical, Sunnyvale, CA) and cerebral flow reversal. The demographics, intraoperative findings, and postoperative results were tabulated and reported. From September 2017 to December 2021, 429 TCAR procedures were attempted within the Memorial Hermann Health System. Preoperatively, all the patients were either asymptomatic with >70% stenosis (66.9%) or symptomatic with >50% stenosis (33.1%). The degree of stenosis was determined using computed tomography angiography and/or duplex ultrasound. We achieved a technical success rate of 99.1%, with the failures attributed to an inability to cross the lesion, an inability to track the stent, visualization of a flow-limiting dissection, and stent maldeployment for one patient each. During the 30-day perioperative period, nine strokes (2.3%) had occurred, three of which had occurred after discharge from the index operation and before the end of the 30-day period. No patient had experienced myocardial infarction. Five patients had died in the perioperative period. Three of the deaths were related to stroke, and two were attributed to cardiopulmonary events secondary to aspiration and likely pulmonary embolus. The mean follow-up after TCAR was 14.5 ± 12.0 months. During the follow-up period, two patients had required reintervention for in-stent stenosis. Ipsilateral to the implanted carotid stent, the overall (including perioperative) stroke incidence was 2.5%. Contralateral to the stent, the stroke incidence was 0.8%. The myocardial infarction rate was 0.8% during follow-up. Mortality in our study population was 5.1% during the follow-up period. After adoption of TCAR across the Memorial Hermann Health System, we found this procedure to be safe and efficacious with minimal perioperative risks comparable to the historically reported results associated with alternative carotid interventions. [ABSTRACT FROM AUTHOR]

Background: Severe carotid stenosis is associated with cognitive impairment, which may be attributed to asymptomatic microembolism and/or chronic hypoperfusion. We aim to evaluate the long-term cognitive and brain connectivity outcomes of carotid artery stenting (CAS) for asymptomatic ≥70% stenosis of the extracranial internal carotid artery (ICA).Methods: We conducted a non-randomized controlled study to compare intensive medical therapy alone (Med) or in combination with carotid artery stenting for the composite vascular events, neuropsychological, and multimodal magnetic resonance perfusion imaging and diffusion tensor imaging outcomes.Results: Sixty-nine patients were followed for a mean of 2.3 years (31 Med, 38 CAS) and 11 patients had composite vascular events of all-cause death, ischemic stroke, or myocardial infarction (6 Med vs 5 CAS). Forty-six asymptomatic subjects completed neuropsychological and multimodality imaging follow-ups (23 Med, 23 CAS). Compared to the Med group, the CAS group had a modest improvement of 12-item delayed verbal memory (8.9 ± 2.4 to 9.8 ± 2.7 vs 9.0 ± 2.1 to 8.9 ± 2.3, p = 0.04), but not in global cognition, attention or executive function, which was associated with increased structural connectivity of fractional anisotropy at the ipsilateral deep white matter. Importantly, the memory improvement was correlated with the perfusion increment at the ipsilateral middle cerebral artery territory.Conclusion: For asymptomatic extracranial carotid steno-occlusion, successful carotid revascularization in addition to intensive medical treatment may potentially benefit cognitive reserve and connectivity strength which are partly attributed to restoration of non-critical hypoperfusion. [ABSTRACT FROM AUTHOR]

Analysis of regional data from the Vascular Quality Initiative (VQI) suggested improved survival for patients undergoing stent placement compared with balloon angioplasty and atherectomy. Using national data from the VQI linked to Medicare claims data through the Vascular Implant Surveillance and Interventional Outcomes Network program, this study aimed to compare the rates of mortality, reintervention, and amputation after endovascular interventions (atherectomy, stenting, and balloon angioplasty) for two separate cohorts: patients with chronic limb-threatening ischemia (CLTI) and patients with claudication. This was a secondary data analysis of Society for Vascular Surgery National VQI data linked to Medicare claims, between October 2016 and December 2019. Patients aged ≥65 years with symptoms of claudication or CLTI and a diagnosis of occlusive disease were included. Urgent or emergent interventions or those with concurrent procedures (endarterectomy, bypass, or bilateral intervention) were excluded. Interventions were grouped into (1) balloon angioplasty only; (2) stent (with or without balloon angioplasty); or (3) atherectomy (alone, with or without stent, with or without balloon angioplasty). Propensity score-matched cohorts were constructed to conduct pairwise intervention comparisons of mortality, reintervention, and amputation rates. Multivariable logistic regression was used to derive propensity scores for each patient. Kaplan-Meier estimates and Cox proportional hazards ratios (HRs) (95% confidence interval [CI]) analyses were performed. A total of 9785 (2665 claudication, 7120 CLTI) eligible patients were identified. After propensity score matching for the CLTI group, 2826, 3608, and 2796 pairs of cases were used to compare balloon angioplasty vs atherectomy, balloon angioplasty vs stent, and stent vs atherectomy, respectively. No statistically significant difference in mortality was observed among all interventions. However, atherectomy was associated with a significant increase in reintervention rate compared with balloon angioplasty (HR, 1.22; 95% CI, 1.06-1.39; P =.01) and compared with stenting (HR, 1.27; 95% CI, 1.10-1.46; P <.01) within the first year after the index procedure. Of note, both atherectomy (HR, 0.82; 95% CI, 0.68-0.98; P <.05) and stenting (HR, 0.76; 95% CI, 0.64-0.90; P <.01) showed lower rates of major amputation when compared with balloon angioplasty within 1 year after the index procedure. In the claudication group, there were no significant differences observed among interventions for peripheral arterial disease for mortality, reintervention, or amputation rates. Further studies are needed to identify appropriate indications for atherectomy, because there may be a subset of patients with CLTI who benefit from this therapy with respect to amputation rates. Until then, caution should be exercised when using atherectomy because it is also associated with higher reintervention rates. [ABSTRACT FROM AUTHOR]

Objectives: In this study, we evaluated the relationship between certain patient and stent characteristics with regards to their association with the development of restenosis.Background: Carotid artery stenosis is a major cause of stroke. Carotid artery stenting is an FDA approved method for the treatment of carotid artery stenosis. However, carotid artery stenting has been fraught with lumen loss and in-stent restenosis. The literature is limited in regard to variables affecting long term patency after carotid artery stenting.Methods: This is a retrospective chart review study investigating the variables affecting the long term patency in patients who underwent carotid artery stenting. The data was analyzed using a Multivariable logistic regression models.Results: 148 patients were included in the study. 123 patients did not develop signs of restenosis after 1 year, while 25 patients developed restenosis defined on annual follow up carotid duplex ultrasound. The odds ratio of developing restenosis for current/former smokers vs. never smokers was 10.1 (p = 0.018), closed vs. open cell design stents was 12.5 (p = 0.008). The odds ratio of developing restenosis decreases by 50.1% for every 1 mm increase in the diameter (p = 0.021). Data was collected and reanalyzed at 3 years to look for any changes in risk factors that become significant which showed that the chance of developing restenosis increases by 11.2% for every 1 mm increase in the length of the stent.Conclusions: Our data suggest that the risk of developing restenosis is elevated in those with a history of previous/current tobacco use; those treated with closed-cell as opposed to open-cell design. We also found that restenosis is positively associated with stent length and inversely associated with stent diameter. The aforementioned factors should be considered in the management of carotid artery stenosis. [ABSTRACT FROM AUTHOR]

Catheter-directed thrombolysis in the treatment of acute lower extremity arterial occlusions often requires several interventional sessions to generate successful outcomes. It is typically an expensive procedure, necessitating extended hospital length of stay (LOS) that may be associated with an increase in both local and systemic hemorrhagic complications. Five years ago, we created the fast-track thrombolysis protocol for arteries (FTTP-A) to deal with these concerns. The goal of our protocol is to re-establish patency during the first session of thrombolysis, thus decreasing costs and complications associated with prolonged periods of thrombolytic exposure. A retrospective study of 42 patients who were treated for acute limb ischemia at our institution by FTTP-A from January 2014 to February 2019 was performed. FTTP-A includes periadventitial lidocaine injection at the arterial puncture site under ultrasound guidance, contrast arteriography of the entire targeted segment, pharmacomechanical rheolytic thrombectomy of the occluded arterial segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and (if deemed necessary) placement of a stent in an area of significant (≥30%) stenosis that is refractory to balloon angioplasty and thrombolysis. After the stenosis or thrombus is cleared, patients are prescribed an oral anticoagulant agent. Primary FTTP-A (50 total interventions) was performed in 42 patients. The median age of patients was 67.2 ± 12.2 years (range, 41-98 years), and 54.8% were male; 59.5% of the procedures were performed on the left lower extremity. Initial arterial access was obtained through the common femoral artery in 39 of 42 cases (92.9%); in the remaining 3 cases, it was obtained in a left bypass access site, a right femoral-popliteal graft, and a right femoral-femoral graft. The mean operative time was 148.9 ± 62.9 minutes (range, 83-313 minutes), and the mean volume of tissue plasminogen activator infused was 9.7 ± 4.0 mg (range, 2-20 mg). The median cost including medications and interventional tools was $4673.19 per procedure. The mean postoperative LOS was 3.1 ± 4.5 days (range, 1-25 days). Median postoperative LOS was 1 day. Mean postoperative follow-up was 27 ± 19.2 months (range, 0-62 months). Single-session FTTP-A was successful in 81% (n = 34/42) of patients; the remaining 8 patients (19%) required a single additional session. Of the 42 patients, 34 (81%) required arterial stenting. Periprocedural complications consisted of one patient with hematuria, which resolved, and one patient with thrombocytopenia, which resolved. No patients experienced rethrombosis within 30 days of FTTP-A. During the 5-year study period, there was no significant local or systemic hemorrhage, limb loss, or mortality related to this protocol. FTTP-A appears to be a safe, efficacious, and cost-effective procedure in the resolution of acute lower extremity arterial occlusions. [ABSTRACT FROM AUTHOR]

Currently, there exists differing conclusions on the role of acute stent malapposition and its role in stent thrombosis (ST). The European Association of Percutaneous Cardiovascular Interventions (EAPCI) consensus recommends that acute malapposition <0.4 mm with longitudinal extension <1 mm need not be corrected since there is no clear correlation of malapposition with adverse clinical outcomes. However, malapposition was identified as the main mechanism of ST in the Bern and PESTO registries, and one of the three leading mechanism in the PRESTIGE study. In this study, a validated perfused benchtop thrombosis model was deployed to evaluate the role of both stent under-expansion (UE) and acute stent malapposition (MA) on thrombus formation in vitro in a controlled reproducible environment. The results showed that UE alone did not result in acute thrombus formation, but UE together with MA did. The data suggested that a MA distance of 0.25 mm led to significant thrombus formation; and a positive correlation exists between the longitudinal extension of the MA and the thrombus volume formed. Experiments in this in vitro model demonstrated that platelets and a thrombosis cascade were activated and developed around large segments of malapposed stent. This was significantly more thrombus formation than in the under-expanded stent region. • Under-expansion alone did not result cause significant thrombosis in this in vitro model. • Under-expansion with malapposition resulted in more thrombus formation. • There is a positive correlation between length of malapposition and thrombus volume. • The longer malapposition segments generated larger measured thrombus volume. [ABSTRACT FROM AUTHOR]

Purpose: Advancements in the endovascular treatment of femoropopliteal atherosclerotic lesions have led to treatment of more complex lesions, particularly long lesions. The aim of this study was to determine the meta-analytic primary patency and need for re-intervention among patients treated for very long lesions (>200 mm) at the femoropopliteal segment and to identify potential risk factors for loss of patency.Methods: This study was performed according to the PRISMA guidelines. A random effects model meta-analysis was conducted, and the I-square was used to assess heterogeneity.Results: Fifty-one studies comprised of 3029 patients were included. The mean lesion length was 269 mm. The primary patency rate at 30 days, 6 m, 1-, 2- and 5-years of follow-up was 98%, 76%, 62%, 55%, and 39% respectively. The incidence of TLR was 16% at one year and 32% at two years. The secondary patency rate at 1, 2, 3 and 5 years was 85%, 71%, 64%, and 64% respectively. Heparin bonded ePTFE covered stents (69%) and paclitaxel eluting stents (73%) demonstrated higher 1-year primary patency rates than self-expanding nitinol stents (55%) or uncoated percutaneous transluminal angioplasty (PTA) with provisional stenting (54%). Lesions treated with a heparin bonded ePTFE covered stent had statistically significant higher odds of remaining patent at 1-year of follow-up (OR: 2.74; 95%CI: 1.63-4.61; p < 0.001) than lesions treated with BMS or PTA. Patients with long femoropopliteal lesions causing critical limb ischemia (CLI) developed restenosis or occlusion more often than patients treated for claudication (HR: 1.63; 95%CI: 1.06-2.49; p = 0.026) during an average follow-up of 26 months.Conclusion: Primary stenting of femoropopliteal TASC D lesions using drug eluting stents or covered stents results in sustained patency over time. PTA or uncoated nitinol stents demonstrated lower patency rates. However, additional comparative studies are needed to determine the efficacy of newer technologies for the treatment of complex femoropopliteal lesions and provide evidence for the most optimal treatment approach. [ABSTRACT FROM AUTHOR]

To establish 30 day and mid term outcomes in patients treated for significant stenoses affecting the proximal common carotid artery (CCA) or innominate artery (IA) with/without tandem disease of the ipsilateral internal carotid artery (ICA). Systematic review of early and mid term outcomes in 1 969 patients from 77 studies (1960–2017) who underwent: (i) hybrid open retrograde angioplasty/stenting of the IA/proximal CCA plus carotid endarterectomy (CEA) in patients with tandem disease of the ipsilateral proximal ICA (n = 700); (ii) isolated open surgery to the IA or proximal CCA (no CEA) (n = 686); or (iii) an isolated endovascular approach to IA or proximal CCA stenoses (no CEA) (n = 583). In the hybrid group with tandem disease (66% involving proximal CCA), the 30 day death/stroke was 3.3%, with a late ipsilateral stroke rate of 3.3% at a median six years follow up. Late re-stenosis was 10.5% for proximal CCA/IA and 4.1% for the ICA. In the isolated open surgery group (78% involving the IA), the 30 day death/stroke was 7%, with a late ipsilateral stroke rate of 1% at a median 12 years follow up. Late re-stenosis within aortic bypasses was 2.6%. In the isolated endovascular group (52% IA, 47% proximal CCA), the majority of procedures were done percutaneously (84%), with a 30 day death/stroke rate of 1.5%. Late ipsilateral stroke was 1% at a median four years follow up, with a re-stenosis rate of 9%. Procedural risks were higher following isolated open surgical interventions involving the proximal CCA/IA, compared with proximal lesions treated by isolated angioplasty/stenting, or in tandem with CEA. This higher morbidity/mortality may, however, reflect a greater proportion of innominate (vs. proximal CCA) lesions in open surgical series, changes in patient selection, time dependent evolution of medical interventions, and publication bias. The available data were limited and related to very different patient groups and management strategies spanning 57 years. Caution is raised, particularly for open surgery IA and CCA surgery, and for any procedures in asymptomatic patients. In symptomatic patients, the data cautiously support an "endovascular first" strategy for isolated proximal CCA/IA lesions and a hybrid approach for tandem proximal CCA/IA and ICA stenoses. [ABSTRACT FROM AUTHOR]

Previously published results of carotid revascularization with both transfemoral stenting and endarterectomy have demonstrated inferior perioperative stroke and death outcomes in neurologically symptomatic patients compared with those without symptoms. This study was completed to establish the real-world, symptom-based perioperative and follow-up outcomes for transcarotid artery revascularization (TCAR). An institutional retrospective review of all TCARs performed outside of clinical trial regulations from 2016 to 2019 was completed. Eligible patients were classified as symptomatic or not based on a history of a unilateral neurologic deficit attributable to an extracranial carotid artery lesion within the previous 180 days. Univariate analysis consisting of Fisher's exact and Student t -tests, as appropriate, were performed between cohorts. Kaplan-Meier analysis was completed to estimate the stroke-free survival at 1 year postoperatively. Within the investigational period, 167 patients (85 symptomatic) qualified for study inclusion. Baseline demographics were roughly equivalent, although symptomatic patients were more likely to be female (28.0% vs 9.4%; P <.01). Procedures in symptomatic patients were associated with higher estimated blood loss (41 mL vs 58 mL; P =.04) and operative time (67 minutes vs 75 minutes; P =.06). We did not find an increased incidence of macroscopic debris in the filter of symptomatic patients after stent deployment. For symptomatic patients, we observed a perioperative (30-day) ipsilateral stroke risk of 1.2% (vs 2.4% in asymptomatic patients; P >.99), a myocardial infarction risk of 0% (vs 0%; P >.99), and a mortality risk of 4.9% (vs 0%; P =.06). Most deaths occurred after procedure-related discharge; as such, in-hospital (from index TCAR) mortality in symptomatic patients was 1.2%. The four perioperative deaths observed in our population were secondary to hemorrhagic stroke, acute on chronic congestive heart failure (n = 2), and unknown causes in the last patient. At 1 year after the procedure, 114 patients (54 symptomatic) had available data. In addition to the perioperative risks, in symptomatic patients we observed a rate of reintervention of 0% (vs 0%; P >.99), ipsilateral stroke of 3.7% (vs 0%; P =.22), >50% in-stent restenosis of 1.9% (vs 0%; P =.47), stent thrombosis of 3.7% (vs 0%; P =.22), and all-cause mortality of 13.0% (vs 10.0%; P =.77). Last, no difference was noted with respect to the 1-year stroke-free survival (P =.17) by Kaplan-Meier estimates. In this institutional series of patients undergoing TCAR, we found that symptomatic patients have a similar perioperative risk of stroke and myocardial infarction as asymptomatic patients. However, we did observe a strong statistical trend suggesting a higher mortality risk in symptomatic patients. There was no difference between cohorts with respect to 1-year stroke-free survival. [ABSTRACT FROM AUTHOR]

The impact of endothelial shear stress (ESS) on vessel remodeling in vessels implanted with bioresorbable scaffold (BRS) as compared to metallic drug-eluting stent (DES) remains elusive. The aim of this study was to determine whether the relationship between ESS and remodeling patterns differs in BRS from those seen in metallic DES at 3-year follow-up. In the ABSORB II randomized trial, lesions were investigated by serial coronary angiography and intravascular ultrasound (IVUS). Three-dimensional reconstructions of coronary arteries post-procedure and at 3 years were performed. ESS was quantified using non-Newtonian steady flow simulation. IVUS cross-sections in device segment were matched using identical landmarks. Paired ESS calculations post-procedure and at 3 years were feasible in 57 lesions in 56 patients. Post-procedure, median ESS at frame level was higher in BRS than in DES, with marginal statistical significance (0.97 ± 0.48 vs. 0.75 ± 0.39 Pa, p = 0.063). In the BRS arm, vessel area and lumen area showed larger increases in the highest tercile of median ESS post-procedure as compared to the lowest tercile. In contrast, in DES, no significant relationship between median ESS post-procedure and remodeling was observed. In multivariate analysis, smaller vessel area, larger lumen area, higher plaque burden post-procedure, and higher median ESS post-procedure were independently associated with expansive remodeling in matched frames. Only in BRS, younger age was an additional significant predictor of expansive remodeling. In a subset of lesions with large plaque burden, shear stress could be associated with expansive remodeling and late lumen enlargement in BRS, while ESS had no impact on vessel dimension in metallic DES. Image 1 • Computational fluid dynamics study can predict vessel behavior in instrumented vessel segments. • Polymeric scaffold has the capability of modifying the vessel dimensions according to the current shear stress. • High endothelial shear stress has impact on expansive remodeling in bioresorbable scaffold implanted vessel segments. • Higher plaque burden post-implantation is associated with expansive vessel remodeling. [ABSTRACT FROM AUTHOR]

• The WEB device is a new tool for treatment of wide-necked brain aneurysms. • The dRA approach is feasible and safe for successful WEB device placement. • Precise catheter manipulation and device placement is maintained with dRA access. • dRA access supports triaxial and quadriaxial catheters assemblies. • dRA access has less associated complications than femoral artery access. Preliminary experience with distal radial artery (dRA) access for diagnostic cerebral angiography and some neurointerventional procedures has proved to be promising with good technical results and a reliable safety profile. Vascular access via the dRA may further improve minimally invasive treatment of intracranial aneurysms. Between July 2019 and June 2020 we identified 11 patients (9 females) with a mean age of 63.5 years who underwent WEB device placement for treatment of their intracranial aneurysm via the dRA approach. The mean aneurysm size (largest diameter) was 6.7 mm. One patient required conversion to femoral access due to severe brachial artery fibromuscular dysplasia. Placement of the WEB device was successful in all other cases via dRA approach. In all but one case, a low profile triaxial catheter system with the 6F Benchmark guide catheter (Penumbra) and 5F Sofia distal access catheter (Microvention) were used. No access related complications were observed. The combination of the intrasaccular WEB device and dRA access represents an ideal approach which offers operators a low risk vascular access and high procedural success by maintaining the ability to precisely place and manipulate the device using low-profile catheter systems. At the same time, this approach offers patients the most minimally invasive experience currently available for treatment of intracranial aneurysms with quick postprocedural recovery, minimal restrictions and low risk for access site complications. [ABSTRACT FROM AUTHOR]

Some have suggested that trabeculae within the transverse sinuses (chordae Willisii) might restrict flow and potentially contribute to thrombus organization. In addition, these structures might be encountered with endovascular procedures within the transverse sinus and are now readily seen on imaging. Therefore as anatomic studies of these structures are scant, the current study aimed to better elucidate these structures within the transverse sinus via a morphologic study in cadavers. Thirty fresh-frozen, cadaveric transverse sinuses were dissected, and their detailed morphology was recorded. Classification schemes were applied based on the anatomy and orientation of each chordae. Chordae were found on 70% of sides and were statistically more likely to be found on right sides (86.6%) (P < 0.01). Three types and 3 classes of chordae were identified. There was a statistically significant difference between sides regarding type of chordae (P = 0.02). To date, a comprehensive anatomic evaluation of the intraluminal chordae of the transverse sinuses has been lacking. Knowledge of these bands is also essential to those performing endovascular procedures of the dural venous sinuses and for those interpreting imaging of these structures. [ABSTRACT FROM AUTHOR]

From their origins as cardiovascular research tools, endovascular techniques have evolved to provide a minimally invasive means of diagnosis and therapy for individuals suffering from occlusive artery disease. The techniques were pioneered by William Harvey, whose work set the stage for all subsequent endovascular experiments. These included the bold self-catheterization procedure performed by Werner Forssmann in 1929, which would lead to his dismissal by his superiors, only to regain respect within the medical community in 1956 on receiving the Nobel Prize. Charles Dotter was the first to understand the true potential of endovascular approaches after a chance recanalization that would catapult arterial catheterization first into the cardiovascular surgical arena, then into neurosurgery for intracranial stenoses. Having been meticulously evaluated and compared with open vascular procedures, endovascular neurosurgery has continued to be refined and optimized. Understanding the history and development of these techniques and their applications in neurosurgery is necessary to appreciate the current clinical utility of these procedures, serving to provide the vascular neurosurgeon a greater array of treatment options for patients. Here we explore the major scientific and technological advancements that facilitated the development of the endovascular approach to cerebral revascularization, as well as current indications and ongoing clinical trials. [ABSTRACT FROM AUTHOR]

Background: The CREST-2 Registry (C2R) was approved by National Institute of Neurological Disorders and Stroke-National Institutes of Health in September 2014 with Centers for Medicare & Medicaid Services, U.S. Food and Drug Administration, and industry collaboration to enroll patients undergoing CAS. The registry credentials interventionists and promotes optimal patient selection, procedural-technique, and outcomes.Objectives: This study reports periprocedural outcomes in a cohort of carotid artery stenting (CAS) performed for asymptomatic and symptomatic carotid stenosis.Methods: Asymptomatic patients with ≥70% and symptomatic patients with ≥50% carotid stenosis, ≤80 years of age, and at standard or high risk for carotid endarterectomy are eligible for enrollment. Interventionists are credentialed by a multispecialty committee that reviews experience, lesion selection, technique, and outcomes. The primary endpoint was a composite of stroke and death (S/D) in the 30-day periprocedural period. Myocardial infarction and access-site complications were assessed as secondary outcomes.Results: As of December 2018, 187 interventionists from 98 sites in the United States performed 2,219 CAS procedures in 2,141 patients with primary atherosclerosis (78 were bilateral). The mean age of the cohort was 68 years, 65% were male, and 92% were white; 1,180 (55%) were for asymptomatic disease, and 961 (45%) were for symptomatic disease. All U.S. Food and Drug Administration-approved stents and embolic protection devices were represented. The 30-day rate of S/D was 1.4% for asymptomatic, 2.8% for symptomatic, and 2.0% for all patients.Conclusions: C2R is the first national registry for CAS cosponsored by federal and industry partners. CAS was performed by experienced operators using appropriate patient selection and optimal technique. In that setting, a broad group of interventionists achieved very low periprocedural S/D rates for asymptomatic and symptomatic patients. [ABSTRACT FROM AUTHOR]

Up to 20% of patients fail to achieve reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) scores of 0–1 after mechanical thrombectomy (MT). Furthermore, underlying intracranial atherosclerotic disease, particularly when associated with >70% residual or flow limiting stenosis, is associated with higher rates of failed MT and high failure risk MT. The aim of this study was to systematically review the procedural and clinical outcomes in patients with failed MT and high failure risk MT. We also explored differences between patients receiving acute rescue stenting compared with medical management alone. A systematic literature search was conducted in Ovid MEDLINE, PubMed, Embase, and Cochrane online scientific publication databases for English language publications from their date of inception until October 2018. Studies including adult patients with acute ischemic stroke because of emergent large vessel occlusion with failed (mTICI score 0–1) or high failure risk MT within the anterior circulation who underwent rescue stenting were included. A systematic review and meta-analysis of proportions was performed. Rescue intracranial stenting after failed MT or high failure risk MT results in improved clinical outcomes compared with patients without stenting (48.5% vs. 19.7%, respectively; P < 0.001), without an increase in the rate of symptomatic intracranial hemorrhage, despite additional use of antiplatelet agents (9.7% vs. 14.1%, respectively; P = 0.04). In patients who fail initial attempts at MT or are high risk for acute reocclusion, rescue intracranial stenting could be considered with the aim to improve functional outcomes. Antiplatelet agents do not increase the risk of hemorrhage in these patients. [ABSTRACT FROM AUTHOR]

Acute type I aortic dissection (AD) complicated by true lumen (TL) collapse and malperfusion downstream is associated with devastating prognosis. The study reports an institutional mid-term experience with TL stabilization by uncovered stents to restore perfusion as a supplement to proximal thoracic aortic surgery. Between January 2007 and May 2017, 181 out of 270 acute type A AD patients were operated on type I AD. Eighteen uncovered stents (10%) were used to expand the aortic TL in presence of visceral and/or peripheral malperfusion. The procedures took place in a hybrid operating room and were combined with proximal aortic surgery. During follow-up (mean ± standard deviation 3.44 ± 2.1 years), the fate of AD was evaluated by computed tomography. Indication for TL stenting included visceral (44%) or peripheral malperfusion (11%) or both (45%). Stenting of aortic branches followed in 33%. All patients underwent proximal repair and were combined with frozen elephant trunk (67%) or retrograde descending aorta stent grafting (11%). Thirty-day mortality was 16.7%. Two-year survival was 71.8%. The false lumen around the uncovered stents remained patent in 89% and the aortic diameter increased 0.1 cm/y. No intimal rupture or occlusion of arteries occurred. In 1 patient, the stented aortic lumen was visualized after 6.3 years and neointima ingrowth covering the nitinol frame was found. In acute type I AD, combined endovascular-surgical procedures in a hybrid operation room setting can be used safely to resolve distal malperfusion. Encapsulation of uncovered stents within the intimal wall provides a stable fundament for endovascular techniques to close entry tears and false lumen. [ABSTRACT FROM AUTHOR]

Carotid artery stenting (CAS) for heavily calcified lesions is controversial due to concern for stent failure and increased perioperative stroke risk. However, the degree to which calcification affects outcomes is poorly understood, particularly in transcarotid artery revascularization (TCAR). With the precipitous increase in TCAR use and its expansion to standard surgical-risk patients, we aimed to determine the impact of lesion calcification on CAS outcomes to ensure its safe and appropriate use. We identified patients in the Vascular Quality Initiative who underwent first-time transfemoral CAS (tfCAS) and TCAR between 2016 and 2021. Patients were stratified into groups based on degree of lesion calcification: no calcification, 1% to 50% calcification, 51% to 99% calcification, and 100% circumferential calcification or intraluminal protrusion. Outcomes included in-hospital and 1-year composite stroke/death, as well as individual stroke, death, and myocardial infarction outcomes. Logistic regression was used to evaluate associations between degree of calcification and these outcomes. Among 21,860 patients undergoing CAS, 28% patients had no calcification, 34% had 1% to 50% calcification, 35% had 51% to 99% calcification, and 3% had 100% circumferential calcification/protrusion. Patients with 51% to 99% and circumferential calcification/protrusion had higher odds of in-hospital stroke/death (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.02-1.6; P =.034; OR, 1.9; 95% CI, 1.1-2.9; P =.004, respectively) compared with those with no calcification. Circumferential calcification was also associated with increased risk for in-hospital myocardial infarction (OR, 3.5; 95% CI, 1.5-8.0; P =.003). In tfCAS patients, only circumferential calcification/protrusion was associated with higher in-hospital stroke/death odds (OR, 2.0; 95% CI, 1.2-3.4; P =.013), whereas for TCAR patients, 51% to 99% calcification was associated with increased odds of in-hospital stroke/death (OR, 1.5; 95% CI, 1.1-2.2; P =.025). At 1 year, circumferential calcification/protrusion was associated with higher odds of ipsilateral stroke/death (12.4% vs 6.6%; hazard ratio, 1.64; P =.002). Among patients undergoing CAS, there is an increased risk of in-hospital stroke/death for lesions with >50% calcification or circumferential/protruding plaques. Increasing severity of carotid lesion calcification is a significant risk factor for stroke/death in patients undergoing CAS, regardless of approach. [ABSTRACT FROM AUTHOR]

Intravenous (IV) periprocedural antiplatelet therapy (APT) for patients undergoing acute carotid stenting during mechanical thrombectomy (MT) is not fully investigated. We aimed to compare the safety profile of IV low dose cangrelor versus IV glycoprotein IIb/IIIa (GP-IIb/IIIa) inhibitors in patients with acute tandem lesions (TLs). We retrospectively identified all cases of periprocedural administration of IV cangrelor or GP-IIb/IIIa inhibitors during acute TLs intervention from a multicenter collaboration. Patients were divided in two groups according to the IV APT regimen at the time of MT procedure: 1) cangrelor and 2) GP-IIb/IIIa inhibitors (tirofiban and eptifibatide). Safety outcomes included rates of symptomatic intracranial hemorrhage (sICH), parenchymal hematoma type 1 and 2 (PH1-PH2), and hemorrhagic infarction type 1 and 2 (HI1-HI2). Sixty-three patients received IV APT during MT, 30 were in the cangrelor group, and 33 were in the GP-IIb/IIIa inhibitors group. There were no significant differences in the rates of sICH (3.3% vs. 12.1%, aOR=0.21, 95%CI 0.02–2.18, p= 0.229), HI1-HI2 (21.4% vs 42.4%, aOR=0.21, 95%CI 0.02–2.18, p= 0.229), and PH1-PH2 (17.9% vs. 12.1%, aOR=1.63, 95%CI 0.29–9.83, p= 0.577) between both treatment groups. However, there was a trend toward reduced hemorrhage rates with cangrelor. Cangrelor was associated with increased odds of complete reperfusion (aOR=5.86; 95%CI 1.57–26.62; p =0.013). In this retrospective non-randomized cohort study, our findings suggest that low dose cangrelor has similar safety and increased rate of complete reperfusion compared to IV GP-IIb/IIIa inhibitors. Further prospective studies are warranted to confirm this association. [ABSTRACT FROM AUTHOR]

We determined the effect of antegrade stent delivery in the descending thoracic aorta on short- and mid-term clinical and imaging outcomes for patients who underwent repair of acute DeBakey type I aortic dissection. Outcomes were evaluated for 178 patients who underwent acute type I aortic dissection between 2005 and 2016 (standard repair, n = 115 [64.6%]; antegrade stent delivery, n = 63 [35.4%]). Propensity score match and multivariable analyses were performed to assess outcomes. The stent and standard repair groups had similar rates of operative mortality (30-day or in-hospital) (12.7% vs 17.4%, P =.41), persistent stroke (6.3% vs 5.3%, P =.75), and persistent paraplegia/paraparesis (1.6% vs 0.9%, P = 1.0). Propensity score match analysis indicated that the operative mortality rate was higher in the standard repair group (P =.059), which the multivariable analysis confirmed. The persistent stroke rate was nonsignificantly higher in the stent group (P =.66). Persistent paraplegia/paraparesis rates were similar in both groups (P = 1.0), and the overall rates of spinal cord ischemia were nonsignificantly higher in the stent group (P =.18). During follow-up (mean duration, 4.6 ± 3.6 y), computed tomography showed that stented patients more often had remodeling of the descending thoracic aorta (P =.0002) and somewhat more often had remodeling of the thoracoabdominal aorta (P =.13). Stented patients also had fewer subsequent procedures (P =.25). The 3- and 5-year survivals were 73.3% ± 6.9% and 49.9% ± 7.6% in the matched stented group and 66.3% ± 9.4% and 41.6% ± 7.7% in the matched standard group, respectively (P =.015 for overall survival). In the short term, antegrade stent delivery was associated with less operative mortality. In the mid-term, promising remodeling of the false lumen was seen in stented patients, as were (nonsignificantly) lower rates of subsequent procedures in the thoracoabdominal aorta. Mid-term survival was also greater in the stented patients. [ABSTRACT FROM AUTHOR]

The Woven EndoBridge (WEB) device, an intrasaccular flow-diverter that does not require long-term antiplatelet use, has recently emerged as an alternative to embolize complex intracranial aneurysms; however, there are limitations to the WEB device. First, it does not immediately secure the aneurysm in most subarachnoid hemorrhage cases. Second, it may not be suitable for embolization of wide-neck aneurysms with an unfavorable aspect ratio. To overcome these limitations, we have used the WEB device in conjunction with stenting and/or coiling. Here, we present a technical note with an illustrated case series and provide a detailed step-by-step description on how the WEB device can be used in adjunct to coiling and/or stenting to achieve successful angiographic results. Accurate sizing of the WEB device before deployment is critical. Larger case series are required to further assess the safety and success of these combined techniques. [ABSTRACT FROM AUTHOR]

Internal jugular vein stenosis (IJVS) results in poor venous outflow and can result in intracranial hypertension. Venous stenting has become a debated topic for correction of this pathology. A 49-year-old male merchant with bilateral IJVS presented with headache, dizziness, and pulsatile tinnitus. He was found to have intracranial hypertension and left IJVS caused by styloid process compression and right IJVS caused by damage of the venous intima. His symptoms improved after undergoing styloidectomy followed by left intra–internal jugular vein (IJV) balloon. However, 1 year later, the prior symptoms reoccurred. At this time, the patient underwent right intra-IJV stenting. After treatment of the contralateral side, the symptoms resolved during the following 3 months. The clinical practice in this case indicated that in patients with bilateral IJVS, a 2-side intervention may be necessary when unilateral correction fails. We advise a staged approach to correction of bilateral IJVS. Styloid compression–induced IJVS should be corrected by styloidectomy in combination with balloon and/or stenting, whereas IJVS induced by venous wall issues needs only stenting. [ABSTRACT FROM AUTHOR]

Background and Purpose: In-stent restenosis (ISR) is unfavorable to the long-term efficacy of carotid angioplasty and stenting (CAS). Inflammation plays a critical role in the development of ISR. The aim of the study was to investigate whether neutrophil to albumin ratio (NAR) is a predictor of ISR in patients undergoing CAS.Methods: We retrospectively recruited patients who underwent CAS. These patients were divided into restenosis group and nonrestenosis group. NAR was examined prior to the CAS procedure. Clinical and radiographic assessments were performed at 6 months and annually after the procedure. ISR was defined as greater than or equal to 50% stenosis in the treated lesion. Cox regression was used to identify predictors of ISR following CAS.Results: During a mean follow-up period of 14.6 months, a total of 459 treated arteries (in 427 participants) were enrolled, among which 72 (15.7%) developed ISR. On multivariate analysis, baseline NAR greater than or equal to13.4, residual stenosis, lesion length, and baseline glucose level were associated with ISR (hazard ratio 1.94[95% confidence interval (CI), 1.08-3.49], 1.09[95% CI, 1.07-1.12], 1.04[95% CI, 1.01-1.06], and 1.01[95% CI, 1.00-1.02], respectively).Conclusion: Elevated preprocedural NAR may be a predictor of ISR in patients undergoing CAS. [ABSTRACT FROM AUTHOR]

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are well-established treatments that have been shown to decrease stroke recurrence in patients with underlying carotid artery disease. We assessed clinical outcome, safety, and restenosis rates for patients who underwent standardized CEA or CAS at our tertiary care center using patient selection criteria based on available scientific evidence. Retrospective chart review of patients who underwent CEA or CAS between 2009 and 2016. In total, 314 cases (204 with CEA and 110 with CAS) were analyzed. Patients were predominantly white (84.4%), men (61.1%) with hypertension (86.9%) and hyperlipidemia (81.8%). Most patients (84.5%) had symptomatic carotid disease. No significant differences were observed in median postoperative National Institutes of Health Stroke Scale and modified Rankin scale (mRS) scores based on pretreatment symptomatic status or treatment modality (CEA vs. CAS). Most patients (85.9%) had favorable outcomes (mRS score 0–2) at a median follow-up of 11.7 months (interquartile range, 1.8–28.8). The perioperative complication rate was low (3.2%), and permanent neurologic deficit was seen in only 3 patients (1%). Restenosis was found in 7.3%, without significant difference between CEA and CAS at last follow-up. Restenosis was asymptomatic in most patients. Our findings in a real-world predominantly symptomatic cohort demonstrate that favorable patient outcomes and low restenosis and complication rates can be achieved with both CEA and CAS by the utilization of a consistent institutional patient selection and treatment process. [ABSTRACT FROM AUTHOR]

The pathophysiology of de novo aneurysm after stenting is poorly understood. Hemodynamic effects may play an important role. We report and discuss the hemodynamic analysis of de novo aneurysm after intracranial stenting. A 51-year-old female underwent angioplasty and coiling for stenosis associated with an aneurysm of the left intracranial carotid artery. Six years later, the follow-up digital subtraction angiography demonstrated a de novo aneurysm at the proximal tine of the Wingspan stent. Computational fluid dynamics simulations showed that stenting for intracranial stenosis resulted in higher oscillatory shear index and lower time-averaged wall shear stress in the neck region of de novo aneurysm. The hemodynamic change after stenting may lead to formation of a de novo aneurysm. After an initial injury that might result from the tine on the endothelial cells, stenting could produce high oscillatory shear index and low time-averaged wall shear stress near the tine, thus potentially inducing de novo aneurysm formation. [ABSTRACT FROM AUTHOR]

A nonbifurcating cervical carotid artery (NBCCA) is a rare anatomic variation of the carotid artery which directly arises from the common carotid artery without forming a bifurcation. A rare case of an NBCCA associated with middle cerebral artery (MCA) stenosis is reported herein. A 70-year-old man was admitted to the hospital for fresh infarctions in the left frontoparietal lobe. The angiographic imaging showed severe atherosclerotic stenosis in the left MCA associated with an ipsilateral NBCCA. The origin of the left internal carotid artery (ICA) was occluded leaving a stump. A tortuous anastomotic vessel arose from the external carotid artery and continued as the cervical ICA. A stent was placed in the left MCA, and the patient recovered uneventfully and without further ischemia during follow-up. Embryogenesis and naming considerations are briefly discussed. This is the first report of an NBCCA accompanied by ipsilateral MCA stenosis. The name hypogenesis/agenesis of the proximal ICA might describe the congenital anatomic variation of an NBCCA more accurately than NBCCA. [ABSTRACT FROM AUTHOR]

Background: Intracranial arterial stenosis (ICAS) is an important cause of ischemic stroke worldwide due to its higher risk of recurrence with medical therapy. Although some large randomized studies failed to show the superiority of surgical treatment compared with medical therapy, the results of medical therapy are not sufficient. There are patients who still benefit from surgical treatment. This retrospective analysis aimed to evaluate the long-term efficacy of surgical therapy with percutaneous transluminal angioplasty and/or stenting (PTA/PTAS) or extracranial-intracranial (EC/IC) bypass surgery for patients with ICAS.Methods: Between October 2005 and December 2016, 55 ICAS patients were treated with PTA/PTAS or EC-IC bypass surgery. Their electronic medical records were retrospectively reviewed and analyzed. The primary outcome was all adverse events beyond 30 days after a revascularization procedure.Results: We performed 21 cases (35%) of PTA, 4 cases (7%) of PTAS, and 34 cases (58%) of EC-IC bypass surgery and the median follow-up duration was 66 months (range 1-144 months). The occurrence rate of the primary outcome was 10.2% and only 1 patient (1.8%) experienced ipsilateral disabling ischemic stroke beyond 30 days. The long-term functional independent survival rate was 83.6%.Conclusions: We demonstrated a long-term favorable outcome of combined surgical intervention for ICAS patients with PTA/PTAS and EC-IC bypass surgery, and the result was better than previously reported outcomes of medical therapy. Additional multicenter studies are required to draw firm conclusions on the efficacy of reduction of recurrent stroke in patients with ICAS. [ABSTRACT FROM AUTHOR]