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Stroke, Volume 56, Issue 4, Page e129-e129, April 1, 2025.

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Circulation, Volume 151, Issue 11, Page 757-759, March 18, 2025.

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Circulation, Ahead of Print. BACKGROUND:The optimal coronary stenting technique for true left main bifurcation lesions is uncertain. EBC MAIN (European Bifurcation Club Left Main Trial) aimed to evaluate clinical outcomes of a stepwise provisional strategy compared with a systematic dual-stent approach.METHODS:EBC MAIN was a randomized, investigator-initiated, open-label, multicenter, parallel-group trial conducted across 35 hospitals in 11 European countries. A total of 467 participants undergoing percutaneous coronary intervention for unprotected true left main bifurcation lesions were randomly assigned to the stepwise provisional strategy (n=230) or an upfront dual-stent approach (n=237). The mean (SD) age was 71 (10) years and 23% of participants were women. The primary end point was a composite of major adverse cardiac events, defined as all-cause mortality, all myocardial infarction, or clinically driven target lesion revascularization. Events were adjudicated by an independent clinical events committee and all analyses were by the intention-to-treat principle.RESULTS:At 3 years, the primary end point occurred in 54 of 230 (23.5%) stepwise provisional and 70 of 237 (29.5%) dual-stent patients (hazard ratio, 0.75 [95% CI, 0.53–1.07];P=0.11). There was no significant difference in all-cause mortality (10.0% versus 13.1%) or myocardial infarction (12.2% versus 11.0%). However, target lesion revascularization was significantly lower in the stepwise provisional group (8.3% versus 15.6%; hazard ratio, 0.50 [95% CI, 0.29–0.86];P=0.013). In this population, the mean side vessel diameter by quantitative angiography was 2.9 mm, and median side vessel lesion length was 5 mm. Significant interactions were identified between the assigned bifurcation strategy and both side vessel diameter and lesion length with respect to the primary outcome (P=0.009 andP=0.005, respectively), with smaller vessels (

Stroke, Volume 56, Issue Suppl_1, Page ATMP76-ATMP76, February 1, 2025. Background and Purpose:In randomized trials, carotid artery stent (CAS) may have higher risk of periprocedural risk compared with carotid endarterectomy (CEA) if performed within the first 7 days after the onset of symptoms.Methods:We analyzed the data from Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). The time interval between the most recent qualifying ischemic event and CAS/CEA procedure was divided in four strata: 1-7 days, 8-14 days, 15-30 days and >30 days. We analyzed the effect of time interval strata between most recent qualifying ischemic event and procedure and procedure type (CEA versus CAS) on peri-procedural stroke and/or death after adjusting for age, gender, symptomatic status and initial severity of stenosis (≥70% versus 30 days (CAS 7.8% versus CAE 4.3%, p=0.12), after the most recent qualifying event. In the multivariate analysis, patients who underwent CAS had higher rate of peri-procedural stroke and/or death (odds ratio [OR] 2.36, 95% confidence interval [CI] 1.25- 4.66) but timing of procedure were not associated with higher rate of peri-procedural stroke and/or death after adjustment for potential confounders. The interaction between procedure type and timing of procedure was not significant. The rate of peri-procedural stroke and/or death was significantly higher in CAS patients who received clopidogrel bolus (without 48-hour maintenance dose) among patients treated 7 days or less after the qualifying event compared with those undergoing CEA (6.6% versus 0%, p=0.012) but was not different between CAS patients who received 48 hours of clopidogrel maintenance and those undergoing CEA (0% versus 0%).Conclusions:The higher rate of peri-procedural stroke and/or death seen with CAS (compared with CEA) within the first 7 days may be attributed to factors such as inadequate pre-procedure antiplatelet medication use. The results of CAS and CEA may become comparable within the first 7 days after the qualifying ischemic event with use of newer generation P2Y12 platelet inhibitors that achieve rapid antiplatelet inhibition.

Stroke, Volume 56, Issue Suppl_1, Page ATMP82-ATMP82, February 1, 2025. Introduction:Aspiration and stent retriever thrombectomy are the primary approaches for endovascular management of posterior circulation stroke. However, the optimal first-line choice of surgical technique remains unclear. This study aims to conduct a systematic review and meta-analysis comparing first-line aspiration with stent retriever thrombectomy in terms of recanalization rates, complications, and clinical outcomes.Methodology:This systematic review and meta-analysis followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Databases searched included PubMed, Embase, Web of Science, Cochrane, and ClinicalTrials.gov, focusing on studies comparing the efficacy and safety of first-line aspiration versus stent retriever thrombectomy for posterior circulation stroke. Data analysis was performed using RevMan version 5.4.1, with statistical significance set at p < 0.05.Result:A total of 21 studies, including 2,521 patients, were analyzed. First-line aspiration demonstrated a significant advantage in terms of successful recanalization (OR = 1.36; 95% CI: 1.04–1.76; p = 0.002) and complete recanalization (OR = 1.41; 95% CI: 0.91–2.20; p = 0.03), both favoring aspiration over the stent retriever technique. Additionally, first-line aspiration was associated with a significantly lower overall complication rate (OR = 0.58; 95% CI: 0.40–0.85; p = 0.005) and a shorter procedural time (SMD = -0.60; 95% CI: -0.81 to -0.40; p < 0.005). However, there were no statistically significant differences between the two techniques in the first pass effect (OR = 1.41; 95% CI: 0.95–2.09; p = 0.09), the need for rescue therapy (OR = 1.01; 95% CI: 0.71–1.44; p = 0.96), 90-day all-cause mortality (OR = 0.95; 95% CI: 0.71–1.27; p = 0.72), and 90-day favorable functional outcome (OR = 1.17; 95% CI: 0.97–1.41; p = 0.11).Conclusion:This meta-analysis suggests that first-line aspiration may offer advantages over stent retrievers for posterior circulation stroke, particularly in terms of recanalization success and procedural safety. However, no significant differences were observed in key clinical outcomes such as mortality and favorable recovery.

Stroke, Volume 56, Issue Suppl_1, Page A71-A71, February 1, 2025. Background:The ideal timing of carotid artery stenting (CAS) in symptomatic internal carotid artery (ICA) stenosis is partly determined by the risk of stroke and/or death associated with timing of the procedure. We evaluated the risk of stroke and/or death within 30 days of CAS, considering various time intervals from the last ipsilateral cerebral/retinal ischemic event, using real-world data.Methods:We analyzed the data for symptomatic patients with ICA stenosis who underwent CAS as part of the national Vascular Quality Initiative (VQI). We divided the time interval between ipsilateral cerebral/retinal ischemic events and CAS into 0-1 days, 2-7 days, 8-14 days, 15-30 days, and 31-180 days. We performed logistic regression analysis to identify the effect of time interval strata between ipsilateral cerebral/retinal ischemic event and CAS on the combined endpoint of any stroke or death within 30 days after adjusting for adjusting for age, gender, severity of stenosis strata, ipsilateral cerebral/retinal ischemic event type, pre-operative use of aspirin, and pre-operative use of antiplatelets other than aspirin.Results:The cohort consisted of 5431 patients, of which 308 patients underwent CAS 0-1 days, 1680 patients 2-7 days, 804 patients 8-14 days, 725 patients 15-30 days, and 1914 patients 31-180 days after the ipsilateral cerebral/retinal ischemic event. The proportion of patients who developed any stroke or death within 30 days was greatest in the shorter time interval group (3.2% for Days 0-1) and lowest in the longer interval group (1.7% for Days 31-180). The risk of any stroke or death within 30 days was significantly higher for those undergoing CAS within 0-1 days (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.01-3.79) compared to those undergoing CAS 31-180 days after the ischemic event. The odds ratio was non significantly different for patients who underwent CAS 2-7 days (OR 1.36, 95% CI 0.87-2.16), 8-14 days (OR 1.47, 95% CI 0.85-2.51), and 15-30 days (OR 1.25, 95% CI 0.67-2.24) after ipsilateral cerebral/retinal ischemic event.Conclusion:Our results highlight the increased risk of stroke and/or death when CAS is performed within the first 2 days after ipsilateral cerebral/retinal ischemic event. Identifying the ideal relationship between timing of CAS after the non-disabling ischemic event and the combined risk of stroke or death within 30 days will allow appropriate triage of symptomatic ICA stenosis patient.

Stroke, Volume 56, Issue Suppl_1, Page A39-A39, February 1, 2025. Background:The Food and Drug Administration (FDA) recommended that intracranial stenting (ICAS) not be performed within 7 days of qualifying cerebral ischemic event due to high rates of 1-month stroke and/or death observed with Wingspan intracranial stent placement in Stenting vs. Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. However, a detailed analysis of the relationship between timing of ICAS and 1-month stroke and/or death has not been performed.Methods:We compared the rates of 1-month stroke and/or death associated with ICAS performed ≤7 days and those >7 days after qualifying cerebral ischemic event in patients recruited in two randomized multicenter trials (SAMMPRIS and Vitesse Intracranial Stent Study for Ischemic Stroke Therapy [VISSIT]. Both trials recruited patients aged ≥ 30 years and ≤ 80 years, who suffered from transient ischemic attack (TIA) or minor ischemic stroke related to high grade (70% to 99% in severity) stenosis in a major intracranial artery and used independent ascertainment for 1 month event rates. We performed logistic regression analysis to identify the effect of time interval strata between qualifying cerebral ischemic event and ICAS on 1-month stroke and/or death rate after adjusting for potential confounders.Results:A total of 108 and 170 patients underwent ICAS ≤7 days and >7 days after the qualifying cerebral ischemic event, respectively. Balloon expandable stent (BES) and self-expanding stent (SES) were used in 54 and 224 patients, respectively. The rates of 1-month stroke and death were 17 of 108 (15.7%) and 30 of 170 (17.6%) in patients treated ≤7 days and those >7 days after qualifying cerebral ischemic event, respectively (p=0.729). There was no difference in the 1-month stroke and/or death rate in patients who underwent ICAS ≤7 days and those >7 days after qualifying cerebral ischemic events (odds ratio 0.074, 95% confidence interval 0.28-2.41) after adjusting for age, gender, severity of stenosis strata, qualifying cerebral ischemic event type (TIA or minor ischemic stroke), and stent used (BES versus SES).Conclusions:We did not observe any increased risk of 1-month stroke and/or death in patients who underwent ICAS ≤7 days and those >7 days after the qualifying cerebral ischemic event. Delaying the ICAS according to current FDA recommendations may not be necessary when ICAS is indicated.

Stroke, Volume 56, Issue Suppl_1, Page AWMP88-AWMP88, February 1, 2025. Background:Intracranial stenting is increasingly performed after thrombectomy failure. Stent selection and procedural strategies are heterogenous between centers. Our aim is to evaluate the clinical and radiological impact of stent design among these patients.Methods:The RESISTANT registry is a multicenter, international, retrospective study of patients with acute ischemic stroke who underwent intracranial stenting from 2016 to 2023. This analysis compares outcomes based on stent type and evaluates the role of pre- and post-stenting angioplasty. The primary endpoint was 90-day good clinical outcome defined as modified Rankin Scale 0 to 2. Secondary outcomes included final reperfusion, and early stent patency (within 48 hours). Safety outcomes included procedural complications, symptomatic intracranial hemorrhage, and in-hospital mortality.Results:Among 859 patients in the RESISTANT registry, 176 underwent intracranial stenting with balloon-mounted stent (BMS) and 683 with self-expandable stent (SES). The Vertebrobasilar location was more frequent in patients who received BMS (46.6% vs 24.0%, p

Stroke, Volume 56, Issue Suppl_1, Page AWMP91-AWMP91, February 1, 2025. Background and Objective:Carotid artery stenting (CAS) is a procedure that has been established as a safe and effective alternative to carotid endarterectomy in high surgical risk patients. There are procedural questions that remain unanswered, specifically, the safety of pre-stent balloon angioplasty versus post-stent versus both. The objective of our study is to understand the risk and safety of these procedural techniques.Methods:Multicenter retrospective data related to angioplasty balloons, stents, complications due to pre and post-stent angioplasty along with the modified Rankin score (mRS) before and after the procedure were collected from January of 2015 until December of 2022. Statistical analysis was performed to correlate this data with risks of complications and clinical outcomes.Results:A total of 1355 patients were enrolled. We found that patients who underwent pre-stent angioplasty, or both (pre and post-stent angioplasty) had a higher risk of complications compared to those who only had post-stent angioplasty. There were more complications in patients who did not undergo post-stent angioplasty as compared to those who did undergo angioplasty (p=0.018, OR=0.513). Follow-up MRS at 30-90 days was higher if the balloons in both pre-stent angioplasty (p=0.016) and post-stent angioplasty (p=0.020) stent angioplasty were not inflated to nominal pressure. Follow up MRS was statistically higher (p=0.01) in patients with open-cell stents than closed-cell stents. Open-cell stents were more likely to undergo post-stent angioplasty (p

Stroke, Volume 56, Issue Suppl_1, Page ADP37-ADP37, February 1, 2025. Object:The introduction of antiplatelet agents is essential in stent-assisted coil embolization (SACE) for the treatment of intracranial aneurysms, and preoperative drug efficacy assessment is important in reducing the risk of ischemic complications. Light Transmission Aggregometry (LTA) is used in our institution to assess drug efficacy, and we analyzed the association between patient background factors, including preoperative LTA values, and perioperative complications in patients who underwent SACE in a retrospective analysis.Methods:Patients who underwent SACE for unruptured cerebral aneurysms from 1 March 2017 to 30 June 2024 were included. Two antiplatelet drugs (aspirin 100 mg and clopidogrel 75 mg /or prasugrel 3.75 mg) were administered 7 days prior to the procedure, and LTA measurements were performed on the day of surgery. The association of each patient’s background factors with ischemic complications during the hospitalization period (≥1 mRS drop) and DWI and SWI positivity rates on the day after surgery was analyzed. To investigate whether LTA value affect DWI positive rate, propensity score-matched analysis was employed to control for age, sex, alcohol consumption, smoking, family history, medical history, aneurysm shape, multiple aneurysms, symptomatic aneurysms, maximum diameter, neck diameter, aneurysm site, left or right, first treatment or not, stent type, number of stents, clopidogrel or prasugrel.Results:During the observation period, 1021 unruptured cerebral aneurysms received endovascular treatment, of which 548 (453 Neuroform Atlas, 17 Enterprise, 78 LVIS) underwent coil embolization with stenting. The mean LTA value on the day of surgery was 44.2 (20-74). Symptomatic ischemic complications were present in two patients (0.4%), but no associated factors were found. Propensity score matching was successful for pairs of 184 aneurysms in the DWI negative group and 184 aneurysms in the DWI positive group. LTA value was still significantly higher in DWI positive group than in DWI negative group (46.96 vs 42.14, p

Stroke, Volume 56, Issue Suppl_1, Page ADP39-ADP39, February 1, 2025. Background:Patients with atrial fibrillation were excluded from clinical trials evaluating carotid artery stent(CAS) or carotid endarterectomy (CEA).We performed this analysis to identify the prevalence of atrial fibrillation and associated outcomes in symptomatic internal carotid artery stenosis patients undergoing CAS or CEA.Methods:We analyzed the data from the National inpatient sample (NIS) between January 2016 to December 2021. We used the ICD-10 to identify patients hospitalized with diagnosis of stroke, TIA, or retinal ischemia with stenosis of carotid artery who underwent CAS or CEA. We divided patients based on presence or absence of atrial fibrillation. We ascertained the end points of intra-procedural and post-procedural cerebral infarction, hemorrhage, discharge home and death in CAS and CEA patients with atrial fibrillation. We compared the endpoints between patients who underwent CAS and those who underwent CEA after propensity score matching.Results:Atrial fibrillation was present in 3,785 (18.3%) of 20,645 patients underwent either CAS or CEA between 2016 and 2021 [18.0% versus 18.8% for CAS or CEA, respectively, p=0.50]. The proportions of patients who developed acute myocardial infarction, respiratory failure, acute kidney injury, or required blood transfusion was higher in patients with atrial fibrillation in both CAS and CEA groups. There was no difference in odds of post-operative stroke and/or death in patients with atrial fibrillation (compared with those without atrial fibrillation) who were treated with CAS (OR 0.99, 95% CI 0.62-1.60, p=0.98) and those treated with CEA (OR 1.09, 95% CI 0.69-1.73, p=0.72) in the multivariate analysis after adjusting for confounders. The length of stay and hospitalization cost was significantly higher in patients with atrial fibrillation (compared with those without atrial fibrillation who were treated with CAS and those treated with CEA). There was no difference in post-operative stroke and/or death (10.7% versus 8.7%, p=0.41) and discharge home (32.4% versus 26.8%, p=0.13) in atrial fibrillation patients who underwent CEA with compared to those underwent CAS in propensity matched analysis.Conclusion:Approximately 1 in 5 patients with symptomatic internal carotid artery stenosis who undergo CAS or CEA have atrial fibrillation in the United States, we did not identify any higher risk of post-operative stroke and/or death in atrial fibrillation patients irrespective of which procedure was undertaken

Stroke, Volume 56, Issue Suppl_1, Page AWP258-AWP258, February 1, 2025. Introduction:Surpass Evolve (SE) is an updated flow diverter stent. While shown to be effective and safe for treating intracranial aneurysms (IA), blood flow analysis is still limited. In this study we constructed IA models with patient-specific internal carotid artery geometry and conducted hemodynamic flow analysis of treatment with implanted SE.Hypothesis:IA neck size affects the flow changes induced by SE.Methods:A model of a patient left internal carotid artery was prepared from the UCLA clinical database. Using computer automated design (CAD) software, two variations of a 4 x 4 mm saccular IA were constructed on the ophthalmic segment: a mid-sized neck (~2 mm) and a wide neck (~5 mm). For each case, a SE device measuring 3.25 mm in diameter and 17 mm in length was added to model treatment, and computational flow dynamic (CFD) simulations of pulsatile blood flow were performed. Post-treatment blood flow was quantitatively compared between IA models, specifically intra-aneurysmal flow velocity, pulsatility index (PI), turbulence, vorticity, and wall shear stress (WSS).Results:Significantly higher flow pulsatility was observed at the neck of the wide neck IA compared to the mid-sized neck IA (PI = 2.96 and 1.66 respectively). Likewise, peak systolic flow velocities were 32.9% and 118% higher at the body and dome respectively in the wide neck case (Fig. 1). Peak systolic WSS values were observed in both cases at the neck facing the direction of blood flow, in which values exceeded 15 Pa for the wide neck case. In the mid-size neck case, WSS in excess of 3 Pa was not observed beyond the neck region, whereas notable propagation of WSS to the body and dome regions were observed in the wide neck case (Fig. 2). Higher flow vorticity was observed in all regions of the IA for the wide-neck case. Flow within the IA of both mid-size and wide neck cases remained mostly laminar with no observable turbulence relative to that in the parent vessel.Conclusion:SE treatment reduced the flow entering the IA at a high curvature area of the ICA. When comparing IA of the same size, increased neck size may reduce the flow reduction effects by 2-fold. We also observed high WSS concentrated at the distal side of the IA neck. As WSS relates to vascular remodeling, following up for distal neck remodeling in post procedure scans could be beneficial to monitor regrowth for SE-treated wide neck IAs.