No abstract

In the treatment of brachiocephalic and subclavian venous obstruction, stent placement shows excellent technical results and helps preserve vascular access for a substantial period. Multiple repeat interventions are, however, frequently required to maintain patency.

ABBREVIATIONS: ASPECTS ϭ Alberta Stroke Program Early Computed Tomography Score; EVT ϭ endovascular therapy; mRS ϭ modified Rankin Scale; mTICI ϭ modified thrombolysis in cerebral infarction; NIHSS ϭ National Institutes of Health Stroke Scale; QI ϭ quality improvement; SAH ϭ subarachnoid hemorrhage; SICH ϭ symptomatic intracranial hemorrhage; SITS-MOST ϭ Safe Implementation of Thrombolysis in Stroke Monitoring Study; TICI ϭ thrombolysis in cerebral infarction; TIMI ϭ thrombolysis in myocardial infarction; TPA ϭ tissue plasminogen activator E ndovascular therapy (EVT) for acute ischemic stroke in selected patients has recently been proved effective in several clinical trials, and the widespread adoption of thrombectomy into routine clinical practice has begun. However, these acute stroke services are resource-intensive, including advanced cerebral im-aging and highly trained multidisciplinary hospital teams rapidly responding to emergency activation. Despite the previous acceptance of intravenous fibrinolysis for acute ischemic stroke and the development of designated stroke centers, 1 ischemic stroke remains a leading cause of adult death and disability. 2 Many patients are not candidates for fibrinolysis, and intravenous therapy is relatively ineffective for severe strokes as a result of large cerebral artery occlusions. Moreover, it is uncertain if the benefits of endovascular stroke treatment in the trial setting can be generalized to clinical care provided by hospitals and teams of varying training, experience, and case volume. In other medical disciplines, rapid technologic advancement required guidelines to utilize these tools effectively and responsibly. 3 Quality-improvement (QI) metrics for the outcomes of endovascular ischemic stroke treatment were published by a multisociety, multispecialty, international consensus group in 2013. 4 These QI metrics have been accepted at a national level in Great Britain and Ireland 5 but have yet to be included into stroke center accreditation requirements in the United States. Subsequent to the publication of the prior QI guidelines, eight randomized trials and several meta-analyses of EVT have been published. 6-20 These randomized trials have established EVT as standard of care when available, 5,21-23 and provide additional data on which to update the metrics and bench-

Primary stent placement should be the treatment of choice in unilateral chronic iliac artery occlusion.

Placement of self-expanding stents in iliac stenoses is technically safe and offers sufficient follow-up patency.

Stent placement in hemodialysis fistulas helps treat lesions that cannot be adequately treated with percutaneous transluminal angioplasty (PTA) alone but has a follow-up patency rate similar to that of PTA. Standard central venous stents have a better patency rate than after PTA.

Acute thrombotic occlusion of native AV fistulae is a major complication of hemodialysis. The results of treatment are believed to be less successful than thrombosis treatment in synthetic grafts. Our results, however, indicate the efficacy of percutaneous treatment in native fistulae, and demonstrate comparable technical results and patency rates.

To evaluate percutaneous transluminal angioplasty (PTA) with a cutting balloon performed in stenosed hemodialysis fistulas and grafts, 19 venous lesions in 15 patients were treated with a cutting balloon with an inflated diameter of 3-6 mm. The grade of stenosis ranged from 40% to 90% (mean, 65% +/- 15 [standard deviation]). Cutting PTA was performed before conventional PTA in seven patients and was followed with conventional PTA with larger balloons in seven patients. The balloon expanded completely in all patients, and no balloon waist remained. The mean grade of stenosis decreased to 14% +/- 9. Cutting PTA increased the technical success of balloon dilation of hemodialysis fistulas and grafts.