Show pageBacklinksCite current pageExport to PDFBack to top This page is read only. You can view the source, but not change it. Ask your administrator if you think this is wrong. ====== Endovascular treatment ====== {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1TqPT7y834vnZ9UPUGFcNJ2GCrD6OEBztvuHET3SsEl3_5osEe/?limit=15&utm_campaign=pubmed-2&fc=20250227053256}} [[Endovascular therapy]], [[Endovascular surgery]] or [[Endovascular neurosurgery]] itself goes by an array of names: [[neuroendovascular surgery]], [[neurointerventional surgery]], [[interventional neuroradiology]] and [[endovascular surgical neuroradiology]], or [[interventional neurology]] (IN), combines catheter-based techniques and imaging for the diagnosis and treatment of specific cerebral and spine conditions. Training is certified by the Committee on Advanced Subspecialty Training (CAST). ---- Doctors who perform endovascular surgery must have an excellent command of two different specialties: [[neurosurgery]] and [[radiology]]. Depending on their backgrounds, doctors who perform endovascular neurosurgery are called either [[endovascular neurosurgeon]]s, [[interventional neuroradiologist]]s, or [[interventional neurologist]]s. Endovascular neurosurgeons trained originally as [[neurosurgeon]]s and then received specialized training in radiology. Interventional neuroradiologists trained originally as radiologists and then received specialized training in neurosurgery. Interventional neurologists trained originally in [[neurology]] followed by training in endovascular neurosurgery. ---- Remarkable developments in the field of [[endovascular]] [[neurosurgery]] have been witnessed in the last decade. The success of [[endovascular therapy]] for [[ischemic stroke treatment]] is now irrefutable, making it an accepted standard of care. Endovascular treatment of [[cerebral aneurysm]]s is no longer limited to primary [[coiling]] but now includes options such as [[stent]] or [[balloon]] assistance and [[flow diversion]] and applications utilizing neck reconstruction, intrasaccular, and bifurcation-specific devices. Balloons, liquid embolic agents, and flow-directed catheters have revolutionized the treatment of [[arteriovenous malformation]]s and [[fistula]]e. The ongoing development of endovascular tools has led to novel and expanding approaches (for example, [[transvenous embolization]] of [[arteriovenous malformation]] and transradial access). With improved technology, transposterior communicating artery access and other endovascular strategies are being applied successfully across the anterior and posterior circulations and to lesions once deemed only surgically approachable. Yet, we would be remiss to attribute the successes of endovascular strategies only to the development of their tools. Improvements in both noninvasive and angiographic imaging (such as three-dimensional road map guidance) have provided a greater understanding of pathologic entities and allowed the pursuit of endovascular cures ((Levy EI, Munich SA, Rosenwasser RH, Kan P, Thompson BG. Introduction: Endovascular Neurosurgery. Neurosurg Focus. 2019 Jan 1;46(Suppl_1):V1. doi: 10.3171/2019.1.FocusVid.Intro. PubMed PMID: 30611172. )). ---- Doctors who perform endovascular surgery must have an excellent command of two different specialties: [[neurosurgery]] and [[radiology]]. Depending on their backgrounds, doctors who perform endovascular neurosurgery are called either [[endovascular neurosurgeon]]s, [[interventional neuroradiologist]]s or [[interventional neurologist]]s. Endovascular neurosurgeons trained originally as [[neurosurgeon]]s and then received specialized training in radiology. Interventional neuroradiologists trained originally as radiologists and then received specialized training in neurosurgery. Interventional neurologists trained originally in [[neurology]] followed by training in endovascular neurosurgery. In fact, endovascular neurosurgery itself goes by an array of names: [[neuroendovascular surgery]], [[neurointerventional surgery]], [[interventional neuroradiology]] and [[endovascular surgical neuroradiology]], for example. ===== History ===== see [[Endovascular Neurosurgery History]]. ---- [[Endovascular]] [[intervention]]s have become an essential part of a [[neurosurgeon]]'s practice. The need for emergent [[neurosurgical procedure]]s is very low among patients undergoing intracranial neuroendovascular procedures. Survival in such patients despite emergent neurosurgical procedures is quite low ((Khatri R, Ansar M, Sultan F, Chaudhry SA, Khan AA, Rodriguez GJ, Tummala RP, Qureshi AI. Requirements for emergent neurosurgical procedures among patients undergoing neuroendovascular procedures in contemporary practice. AJNR Am J Neuroradiol. 2012 Mar;33(3):465-8. doi: 10.3174/ajnr.A2787. Epub 2011 Nov 24. PubMed PMID: 22116112.)). A study suggest potential gaps in the training of neurosurgery residents with regard to endovascular neurosurgery. In an era of minimally invasive therapies, changes in residency curricula may be needed to keep pace with the ever-changing field of neurosurgery ((Chalouhi N, Zanaty M, Tjoumakaris S, Manasseh P, Hasan D, Bulsara KR, Starke RM, Lawson K, Rosenwasser R, Jabbour P. Preparedness of neurosurgery graduates for neuroendovascular fellowship: a national survey of fellowship programs. J Neurosurg. 2015 Apr 3:1-7. [Epub ahead of print] PubMed PMID: 25839924.)) The [[femoral artery]] is usually punctured below the [[inguinal ligament]] for [[neuroendovascular procedure]]s with a 18-19 gauge needle. To place the wire with [[Seldinger technique]] in the artery with removal of the percutaneous needle and the introduction of the sheath ((Osborn AG, Diagnostic Cerebral Angiography.Lippincott Williams & Wilkins, Philadelphia, PA: 1999.)). The sheath is removed at the end of the procedure, then manual compression should be performed for 10-20 minutes to achieve hemostasis. This minimizes the risk of local and embolic complications. Remove the sheath only when the [[Activated Partial Thromboplastin Time]] (aPTT) has returned to normal (< 36 secs) or when the [[Activated Clotting Time]] (ACT) is < 170. see [[femoral arterial closure device]]. Endovascular treatment by mechanical [[thrombectomy]] will be increasingly chosen as an adjunctive or alternative to intravenous thrombolysis. To apply this form of stroke treatment is associated with the challenge of optimal periinterventional treatment. The patient has to be identified, counselled, prepared, monitored, cardiovascularly stabilized, possibly sedated and ventilated, and postprocedurally treated in the optimal way. However, most aspects of periinterventional treatment have as yet not been clarified and require prospective research. Among these, the question of general anesthesia vs conscious sedation has received most attention and may be the most crucial one. Based on a great amount of retrospective data, it appears reasonable to start the intervention under conscious sedation of the non-intubated patient with standby measures for emergent intubation, until prospective randomized trials have clarified that issue. Periinterventional management will significantly affect the success of recanalization ((Bösel J. Management of the Interventional Stroke Patient. Curr Treat Options Neurol. 2015 Oct;17(10):45. doi: 10.1007/s11940-015-0376-z. PubMed PMID: 26387814. )). The expansion of endovascular techniques for [[intracranial aneurysm]]s has led to a global decrease in [[vascular neurosurgery]] activity. This situation might impact neurosurgeons' level of expertise, even though they all might have to deal with this surgically challenging pathology, and pleads for the use of training and simulation programmes dedicated to neurovascular surgery ((Le Reste PJ, Henaux PL, Riffaud L, Haegelen C, Morandi X. Influence of cumulative surgical experience on the outcome of poor-grade patients with ruptured intracranial aneurysm. Acta Neurochir (Wien). 2015 Jan;157(1):1-7. doi: 10.1007/s00701-014-2241-3. Epub 2014 Sep 25. PubMed PMID: 25248329.)). ===== Embolization device ===== see [[Embolization device]] ===== Indications ===== [[Endovascular Treatment Indications]]. ===== Contraindications ===== ● uncorrected (life-threatening) bleeding disorders ● relative contraindications: ○ poor renal function (due to iodine dye load): hemodialysis can be arranged in emergent situations; alternatively, the patient may be hydrated and monitored for a return to baseline creatinine ○ connective tissue disorder that predisposes to vessel dissection ○ severe allergy to iodine contrast: requires prior administration of “dye allergy prep” ○ Major atheroma of the aortic arch or plaque/atherosclerosis of great vessels (innominate, subclavian, [[common carotid artery]]) due to the high risk for thromboembolic complications ○ for spinal angiography: thoracic [[aortic aneurysm]] (relative) ====Technique==== A stable [[intracranial guide catheter]] position within the intracranial vasculature is critical for safe, successful endovascular treatment ===== Antiplatelet Therapy in Endovascular Treatment ===== [[Antiplatelet Therapy in Endovascular Treatment]]. ====Pharmacological Agents==== [[Eptifibatide]] [[Abciximab]] [[Tirofiban]] Neuroendovascular treatment in Japan is increasing and the outcomes of such therapy are clinically acceptable. Details of each type of treatment will be investigated in sub-analyses of the database ((Sakai N, Yoshimura S, Taki W, Hyodo A, Miyachi S, Nagai Y, Sakai C, Satow T, Terada T, Ezura M, Hyogo T, Matsubara S, Hayashi K, Fujinaka T, Ito Y, Kobayashi S, Komiyama M, Kuwayama N, Matsumaru Y, Matsumoto Y, Murayama Y, Nakahara I, Nemoto S, Satoh K, Sugiu K, Ishii A, Imamura H. Recent Trends in Neuroendovascular Therapy in Japan: Analysis of a Nationwide Survey-Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2. Neurol Med Chir (Tokyo). 2013 Dec 27. [Epub ahead of print] PubMed PMID: 24390188.)). The risk of [[hemorrhage]] must be considered when using [[anticoagulation]] and antiplatelet therapy in patients requiring [[ventriculostomy]]. Interventionalists must not only work closely with neurosurgeons when it is anticipated that a ventriculostomy may be needed but also ensure that there is good communication with the neurosurgical team during the postprocedural period ((Ross IB, Dhillon GS. Ventriculostomy-related cerebral hemorrhages after endovascular aneurysm treatment. AJNR Am J Neuroradiol. 2003 Sep;24(8):1528-31. PubMed PMID: 13679264.)). ===== Complications ===== [[Endovascular intervention complications]]. ===== Books ===== [[Video Atlas of Neuroendovascular Procedures]] endovascular_treatment.txt Last modified: 2025/02/27 10:34by 127.0.0.1