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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Iatrogenic Vessel Dissection in Neuroendovascular Therapy: A JR-NET4 Nationwide Registry Analysis
Natsuhi Sasaki1, Akira Ishii2, Hirotoshi Imamura1
1From the Division of Interventional Neuroradiology (N.S.), Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; Department of Neurosurgery (N.S., C.S.), Regulatory Science of Medical Device Development and Innovation (C.S.), Kyoto University Graduate School of Medicine, 54 Shogoin Kawaharacho, Sakyo-Ku, Kyoto, 606-8507, Japan; Department of Neurosurgery (A.I.), Juntendo University, 3- 1-3 Hongo, Bunkyo-Ku, Tokyo, 113-8431, Japan; Department of Neurosurgery (H.I.), Kobe City Medical Center General Hospital, 1-1-2 Minatojimaminami-machi, Chuoku, Kobe, Hyogo, 650-0047, Japan; Department of Neurosurgery (T.S.), Kindai University, 377-2 Onohigashi, Sayama, Osaka, 589-8511, Japan; Department of Neurosurgery (K.I.), National Cerebral and Cardiovascular Center, 6-1 Kishibe- Shimmachi, Suita, Osaka, 564-8565, Japan; Department of Neurosurgery (S.Y.), Hyogo Medical University, 1-1 Mukogawacho, Nishinomiya, Hyogo, 663-8501, Japan; Department of Neurosurgery (Y.M.), University of Tsukuba, 2-1-1 Amakubo, Tsukuba, Ibaraki, 305-8576, Japan and Department of Neurosurgery (N.S.), Seijinkai Shimizu Hospital, 11-2 Yamadanakayoshimicho, Nishikyo-Ku, Kyoto, 615-8237, Japan.
Background And Purpose:
Iatrogenic vessel dissection is an uncommon complication of neuroendovascular therapy. Owing to its low incidence, procedure-specific incidence and associated factors have remained incompletely defined. While iatrogenic vessel dissection typically follows a benign course, severe outcomes have occasionally been reported, and the determinants of this exceptional course are unclear. We aimed to establish procedure-specific benchmark incidence, identify associated factors, and assess its outcome impact using a large nationwide registry.
Materials And Methods:
We conducted a retrospective analysis using the Japanese Registry of Neuroendovascular Therapy 4, covering 2015-2019. Dissection incidence, associated baseline and procedural factors, and 30-day functional outcomes were evaluated across nine treatment categories. Procedure-specific multivariable logistic regression was used to estimate adjusted associations with 30-day mRS. Among dissection cases without other complications (isolated dissection), secondary intracranial hemorrhage or cerebral infarction and their associations with outcomes were explored. These analyses were also conducted separately for intracranial and extracranial treatment sites.
Results:
A total of 53,402 procedures were included. Overall incidence was 0.65% (348 procedures), ranging from 0.12% in vasospasm treatment to 3.48% in intracranial angioplasty/stenting. Dissection occurred more frequently in emergency procedures and under local anesthesia. Dissection was consistently more frequent with flow diverters, angioplasty/stenting, and lesions requiring balloon dilation or stent deployment, including high-grade stenosis, total occlusion, and atherothrombotic occlusion. In multivariable models, an independent association with mRS 5-6 was observed only in aneurysm treatment (adjusted OR, 2.48; 95% CI, 1.05-5.40). Among 296 isolated dissections, no mRS decline occurred in 265 (89.5%). Decline was more frequent with secondary hemorrhage or infarction than without (26/57 [46%] vs 5/239 [2.1%]; P < .001). At intracranial treatment sites, decline was more frequent with hemorrhage than with infarction (16/25 vs 8/25; P = .047), and death occurred only after hemorrhage (6/25 vs 0/25; P = .02).
Conclusions:
Iatrogenic vessel dissection incidence varied substantially across neuroendovascular procedures and was most consistently associated with procedures and lesions requiring balloon dilation or stent deployment. Most dissections did not lead to clinical deterioration; early clinical impact was associated mainly with secondary intracranial hemorrhage or infarction rather than with the dissection itself.
