Endovascular Surgery
RCT: Adjunctive Middle Meningeal Artery Embolization Reduces Reoperation in Subdural Hematoma
24 Nov, 2024 | 13:53h | UTCBackground: Subacute and chronic subdural hematomas are common neurosurgical conditions with a high recurrence rate after surgical evacuation, affecting 8% to 20% of patients. Middle meningeal artery embolization (MMAE) is a minimally invasive procedure targeting the blood supply to these membranes. Preliminary studies suggest that adjunctive MMAE may reduce hematoma recurrence, but its impact on reoperation risk remains unclear.
Objective: To determine whether adjunctive MMAE reduces the risk of hematoma recurrence or progression leading to repeat surgery within 90 days compared to surgery alone in patients with symptomatic subacute or chronic subdural hematoma.
Methods: In this prospective, multicenter, randomized controlled trial, 400 patients aged 18 to 90 years with symptomatic subacute or chronic subdural hematoma requiring surgical evacuation were randomly assigned to receive either MMAE plus surgery (n=197) or surgery alone (n=203). The primary endpoint was hematoma recurrence or progression leading to repeat surgery within 90 days after the index treatment. The secondary endpoint was deterioration of neurologic function at 90 days, assessed using the modified Rankin Scale.
Results: Hematoma recurrence or progression requiring repeat surgery occurred in 8 patients (4.1%) in the MMAE plus surgery group versus 23 patients (11.3%) in the surgery-alone group (relative risk, 0.36; 95% CI, 0.11 to 0.80; P=0.008). Functional deterioration at 90 days was similar between groups (11.9% vs. 9.8%; risk difference, 2.1 percentage points; 95% CI, −4.8 to 8.9). Mortality at 90 days was 5.1% in the MMAE group and 3.0% in the control group. Serious adverse events related to the embolization occurred in 4 patients (2.0%), including disabling stroke in 2 patients.
Conclusions: Adjunctive MMAE combined with surgery significantly reduced the risk of hematoma recurrence or progression requiring reoperation within 90 days compared to surgery alone. However, there was no significant difference in neurologic functional deterioration, and the procedure was associated with procedural risks.
Implications for Practice: MMAE may be considered as an adjunct to surgical evacuation in patients with subacute or chronic subdural hematoma to reduce reoperation risk. Clinicians should carefully weigh the potential benefits against the risks of procedural complications, including stroke.
Study Strengths and Limitations: Strengths include the randomized controlled design and multicenter approach, enhancing generalizability. Limitations involve the open-label design, introducing potential bias since the primary endpoint was based on surgeon judgment. A substantial loss to follow-up (13.2%) could affect results, and the study was not powered to detect differences in mortality or serious adverse events.
Future Research: Further studies with larger sample sizes are needed to fully evaluate the safety and efficacy of MMAE, including long-term outcomes. Research should focus on optimizing patient selection and assessing the procedure’s impact on mortality and serious adverse events.
RCT: Renal Denervation Reduces Blood Pressure in Chinese Patients With Uncontrolled Hypertension
7 Sep, 2024 | 14:57h | UTCStudy Design and Population: This was a prospective, multicenter, randomized, sham-controlled trial investigating the efficacy and safety of catheter-based radiofrequency renal denervation (RDN) in Chinese patients with uncontrolled hypertension despite standardized triple antihypertensive therapy. A total of 217 patients (mean age 45.3 years, 21% female) were randomized 1:1 to receive RDN or a sham procedure.
Main Findings: At 6 months, patients who underwent RDN showed a significantly greater reduction in 24-hour ambulatory systolic blood pressure (−13.0 mm Hg) compared to the sham group (−3.0 mm Hg), with a baseline-adjusted difference of −9.4 mm Hg (P<0.001). Significant reductions were also observed in 24-hour diastolic BP and office systolic and diastolic BP. One access site complication occurred in the RDN group but resolved without further issues.
Implications for Practice: This trial demonstrates that RDN is an effective and safe option for reducing blood pressure in patients with uncontrolled hypertension, offering a potential adjunct to antihypertensive therapy in this population. Further research may solidify its role in managing resistant hypertension.
Reference: Jiang X et al. (2024). Efficacy and Safety of Catheter-Based Radiofrequency Renal Denervation in Chinese Patients With Uncontrolled Hypertension: The Randomized, Sham-Controlled, Multi-Center Iberis-HTN Trial. Circulation. https://doi.org/10.1161/CIRCULATIONAHA.124.069215
Link: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.124.069215
RCT: Thrombectomy improves outcomes in acute stroke with large infarcts – N Engl J Med
25 May, 2024 | 19:35h | UTCStudy Design and Population: This randomized clinical trial investigated the efficacy of thrombectomy in combination with standard medical care versus medical care alone in patients with acute stroke and large infarcts. Participants included 333 patients with proximal cerebral vessel occlusion in the anterior circulation, presenting within 6.5 hours of symptom onset. They were randomized in a 1:1 ratio to either undergo thrombectomy or receive only medical care. An Alberta Stroke Program Early Computed Tomographic Score of ≤5 was used to define large infarcts.
Main Findings: The primary outcome, assessed by the modified Rankin scale score at 90 days, showed a median score of 4 in the thrombectomy group compared to 6 in the control group, indicating better functional outcomes with thrombectomy (generalized odds ratio, 1.63; 95% CI, 1.29 to 2.06; P<0.001). Mortality at 90 days was significantly lower in the thrombectomy group (36.1%) compared to the control group (55.5%) with an adjusted relative risk of 0.65. However, thrombectomy was associated with a higher rate of symptomatic intracerebral hemorrhage (9.6% vs. 5.7% in the control group).
Implications for Practice: The findings suggest that thrombectomy, when added to standard medical care, can significantly improve functional outcomes and reduce mortality in patients with large infarct strokes. However, the increased risk of symptomatic intracerebral hemorrhage must be considered when deciding on this intervention. These results support the broader use of thrombectomy in clinical settings with similar patient profiles but underscore the need for careful risk-benefit analysis due to the potential for serious hemorrhagic complications.
Reference (link to abstract – $ for full-text):
M-A | No significant difference between thrombo-aspiration and stent-retrieval thrombectomy in ischemic stroke treatment
22 Jun, 2023 | 15:00h | UTCSummary: Different types of percutaneous endovascular treatments for acute ischemic stroke – Cochrane Library
Guideline | Management of type B aortic dissection
10 May, 2023 | 15:32h | UTC
RCT | Best endovascular treatment first strategy yields better outcomes for chronic limb ischemia vs. vein bypass first strategy
3 May, 2023 | 15:39h | UTCCommentary: BASIL-2 Supports Endo-First Strategy for CLTI With Infrapopliteal Disease – TCTMD
M-A | Endovascular revascularization strategies for aortoiliac and femoropopliteal artery disease
12 Apr, 2023 | 13:01h | UTCCommentary: Endovascular Revascularization in Intermittent Claudication – American College of Cardiology
SR | Remote ischemic preconditioning for vascular and endovascular surgical procedures
12 Apr, 2023 | 13:00h | UTC
SR | Totally percutaneous vs. surgical cut‐down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair
23 Feb, 2023 | 13:21h | UTC
M-A | Drugs to reduce bleeding in major open vascular or endovascular surgery – not enough evidence to guide treatment
21 Feb, 2023 | 11:44h | UTCSummary: The article is a systematic review and network meta-analysis of randomized controlled trials (RCTs) on the effectiveness and safety of anti-fibrinolytic and hemostatic drugs and agents to reduce bleeding and the need for blood transfusion in people undergoing major vascular surgery or endovascular procedures. The authors searched multiple databases and trial registries and included 22 RCTs with 3,393 participants analyzed. Due to a lack of data, the authors are uncertain whether any systemic or topical treatments may improve outcomes, emphasizing that larger trials with clinically relevant outcomes are needed.
Cohort Study | Procedural characteristics and outcomes of transcatheter interventions for aortic coarctation
13 Jan, 2023 | 13:16h | UTC
Commentary on Twitter
Practice patterns and acute outcomes of #transcatheter #coarctation interventions in the @ACCinTouch #NCDR IMPACT Registry ➡️ https://t.co/tkFJ3tiSvu@DrAdaStefanescu @AmiBhattMD @erichorlick pic.twitter.com/lzVr6KV0mE
— MyJSCAI (@MyJSCAI) September 27, 2022
Cohort Study | Surveillance of long-term outcomes of devices after endovascular abdominal aortic aneurysm repair.
10 Nov, 2022 | 14:00h | UTC
Commentary on Twitter
Long term reintervention and rupture after endovascular abdominal aortic aneurysm repair varies by device manufacturer, and failures are common, especially for early generation devices, finds this study by @dartmthsurghsr and colleagueshttps://t.co/0FwQdBaMkc
— The BMJ (@bmj_latest) October 25, 2022
2022 ACC/AHA Guideline for the diagnosis and management of aortic disease.
3 Nov, 2022 | 14:21h | UTCNews Release: ACC, AHA Issue Aortic Disease Guideline – American Heart Association
RCT | Intensive BP control after thrombectomy for ischemic stroke is associated with increased risk of poor functional outcomes.
2 Nov, 2022 | 14:26h | UTCIntensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial – The Lancet (link to abstract – $ for full-text)
Commentary on Twitter (thread – click for more)
1/ A #MorningPaper from @TheLancet on #Stroke. This large study randomised 821 patients into aggressive BP management (sBP <120mmHg) vs 140-180mmHg. Trial stopped early due to safety concerns. @neuro_at_ic @e1v1m1 @SomaBanerjee73 @StrokeImperialhttps://t.co/vnvnnI1KLq
— Kevin Tsang (@drtintin99) October 29, 2022
Post-trial follow-up | Endarterectomy vs. stenting vs. best medical treatment for asymptomatic carotid artery stenosis.
2 Nov, 2022 | 14:25h | UTCCarotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis: 5-year results of a multicentre, randomised controlled trial – The Lancet Neurology (link to abstract – $ for full-text)
Commentary on Twitter
5 year results of SPACE 2 in @TheLancetNeuro show low event rates in all groups. With best medical therapy only 3.1%, CEA+BMT 2.5%, CAS+BMT 4.4%. Study underpowered for firm conclusions. @CREST2_Study will have close to 2500 pts@ESOstroke @WorldStrokeOrg https://t.co/nUE0WxWidk
— Seemant Chaturvedi (@ChaturvediNeuro) September 17, 2022
Asymptomatic carotid artery stenosis: a summary of current state of evidence for revascularization and emerging high-risk features.
1 Nov, 2022 | 11:46h | UTCRelated:
Commentary on Twitter
Latest in #carotid– https://t.co/ugL2tGBoLn – Woo Kim H et al. compile the evidence surrounding high-risk clinical and imaging features of #asymptomatic carotids that might identify higher-risk lesions. @s_hyunwookim pic.twitter.com/3E8P0EWRRl
— JNIS (@JNIS_BMJ) September 14, 2022
Multimodality imaging and image guidance techniques for endovascular ascending aortic repair.
26 Oct, 2022 | 14:37h | UTC
RCTs | Thrombectomy improved recovery in basilar artery stroke but increased procedural complications and hemorrhages.
14 Oct, 2022 | 14:20h | UTCStudy 1: Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion – New England Journal of Medicine (link to abstract – $ for full-text)
Study 2: Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion – New England Journal of Medicine (link to abstract – $ for full-text)
Related:
Commentary on Twitter
In 340 Chinese patients with basilar-artery occlusion, endovascular treatment resulted in better neurologic outcomes than medical care. Approximately one third of patients underwent intravenous thrombolysis. https://t.co/ZqHirYnjoH pic.twitter.com/fuRV3rFWX7
— NEJM (@NEJM) October 13, 2022
Cohort Study | Determinants of drug-coated balloon failure in patients undergoing femoropopliteal arterial intervention.
29 Sep, 2022 | 13:33h | UTC
ESVS Clinical practice guidelines on radiation safety.
28 Sep, 2022 | 13:46h | UTC
RCT | Among patients with symptomatic intracranial stenosis, the addition of stenting to medical therapy is not better at reducing the risk of stroke or death compared to medical therapy alone.
10 Aug, 2022 | 15:36h | UTCEditorial: Therapeutic Strategies for Intracranial Atherosclerosis – JAMA (free for a limited period)
Commentary: Stenting Hits Another Wall in Intracranial Stenosis Stroke – MedPage Today (free registration required)
Commentary on Twitter
Findings of this #RandomizedClinicalTrial do not support the addition of percutaneous transluminal angioplasty and stenting to medical therapy for the treatment of patients with symptomatic severe intracranial atherosclerotic stenosis. https://t.co/X9qi3WQ0JC pic.twitter.com/rH6aDo4GjV
— JAMA (@JAMA_current) August 9, 2022
RCT | In patients with large vessel occlusion stroke, intravenous Tirofiban before endovascular thrombectomy does not improve functional outcomes.
10 Aug, 2022 | 15:34h | UTCEffect of Intravenous Tirofiban vs Placebo Before Endovascular Thrombectomy on Functional Outcomes in Large Vessel Occlusion Stroke: The RESCUE BT Randomized Clinical Trial – JAMA (free for a limited period)
See also: Visual Abstract
Commentary: RESCUE BT: IV Tirofiban No Help During Stroke Thrombectomy – TCTMD
Trends in thoracic aortic aneurysm hospital admissions, interventions and mortality in England between 1998 to 2020: An observational study.
3 Aug, 2022 | 13:55h | UTC
Systematic Review | Type of anesthesia for acute ischemic stroke endovascular treatment.
21 Jul, 2022 | 13:06h | UTCType of anaesthesia for acute ischaemic stroke endovascular treatment – Cochrane Library
Consensus Recommendations: Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities.
22 Jun, 2022 | 11:25h | UTC