Endovascular Introduction


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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
    Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner.
    There are a number of sources of stem cells, namely, adult cells generally extracted from bone marrow, cord cells, extracted during pregnancy and cryogenically stored, and embryonic cells, extracted from an embryo before the cells start to differentiate. As to source and method of acquiring stem cells, harvesting autologous adult cells entails the least risk and controversy.
    Autologous stem cells are obtained from the patient’s own body; and since they are the patient’s own, autologous cells are better than both cord and embryonic sources as they perfectly match the patient’s own DNA, meaning that they will never be rejected by the patient’s immune system. Autologous transplantation is now happening therapeutically at several major sites world-wide and more studies on both safety and efficacy are finally being announced. With so many unrealized expectations of stem cell therapy, results to date have been both significant and hopeful, if taking longer than anticipated.
    What’s been the Holdup?
    Up until recently, there have been intense ethical debates about stem cells and even the studies that researchers have been allowed to do. This is because research methodology was primarily concerned with embryonic stem cells, which until recently required an aborted fetus as a source of stem cells. The topic became very much a moral dilemma and research was held up for many years in the US and Canada while political debates turned into restrictive legislation. Other countries were not as inflexible and many important research studies have been taking place elsewhere. Thankfully embryonic stem cells no longer have to be used as much more advanced and preferred methods have superseded the older technologies. While the length of time that promising research has been on hold has led many to wonder if stem cell therapy will ever be a reality for many disease types, the disputes have led to a number of important improvements in the medical technology that in the end, have satisfied both sides of the ethical issue.
    CCSVI Clinic
    CCSVI Clinic has been on the leading edge of MS treatment for the past several years. We are the only group facilitating the treatment of MS patients requiring a 10-day patient aftercare protocol following neck venous angioplasty that includes daily ultrasonography and other significant therapeutic features for the period including follow-up surgeries if indicated. There is a strict safety protocol, the results of which are the subject of an approved IRB study. The goal is to derive best practice standards from the data. With the addition of ASC transplantation, our research group has now preparing application for member status in International Cellular Medicine Society (ICMS), the globally-active non-profit organization dedicated to the improvement of cell-based medical therapies through education of physicians and researchers, patient safety, and creating universal standards. For more information please visit http://www.neurosurgeonindia.org/
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  • Dural sinus thrombosis with impaired vision. s/p thrombolysis and sinus stent. Vision improved after treatment

  • Endovascular Introduction

    1. 1. Endovascular therapy
    2. 2. History • 1927 Antonio Egas Moniz • Cerebral angiography • 1960 Luessenhop and Spence • AVM embolization • 1969 Fedor A. Serbinenko • Balloon occlusion of cerebral artery
    3. 3. History • 1974 Gruntzig & Hopff • Angioplasty for stenotic vessels • 1987 Sigwart • Coronary stent • 1995 Guido Guglielmi : GDC coil
    4. 4. Present • Endovascular measures • Occlude • coils, liquid and particle embolizers, balloon, stent • Open up • balloon, stent, drugs
    5. 5. Present • Endovascular therapy can treat • Aneurysm, AVM, AVF, CCF • Intra- and extracranial arterial stenosis • Acute ischemic stroke • Dural sinus thrombosis • Nearly all cerebrovascular diseases can be treated
    6. 6. Acute stroke • Thrombolysis • intra-venous rTPA • intra-arterial urokinase, rTPA... • mechanical • thrombus aspiration, thrombus buster, stenting
    7. 7. Penumbra system • CE and FDA certificated • Indication for use (501k document) • Revasculization of patients with acute ischemic stroke secondary to intracranial large vessel occlusive disease within 8 hours of symptom onset
    8. 8. System Components • Reperfusion Catheter – Optimized design for efficient navigation and aspiration • Separator™ – Operator controlled movement clears Reperfusion Catheter enabling continuous aspiration. • Penumbra Aspiration Pump & Aspiration Tubing – Provides continuous, physiologic vacuum that can be controlled from the sterile field. 10 1274.C
    9. 9. Aspiration System Matched 041 Separator™ Reperfusion Catheter 041 Matched 032 Separator Reperfusion Catheter 032 Matched 026 Separator Reperfusion Catheter 026 11 1274.C
    10. 10. Aspiration System Matched 041 Separator™ Reperfusion Catheter 041 Matched 032 Separator Reperfusion Catheter 032 Matched 026 Separator The Penumbra System uses a unique Microcatheter and Separator™ Reperfusion debulking approach to intracranial revascularization. based thrombus Catheterwith the Penumbra Aspiration Pump and Accessories, its Together 026 advantages include: • Proximal working position 11 1274.C • Continuous aspiration
    11. 11. Budapest Case #3: Exchanged Devices • 041 Reperfusion Catheter tracked into Temporal branch • Became clogged • Removed Separator 041 Separator bulb • Temporal branch opened 13 1274.C
    12. 12. Budapest Case #3: Exchanged Devices • 041 Reperfusion Catheter tracked into Temporal branch • Became clogged • Removed Separator 041 Separator bulb • Temporal branch opened 13 1274.C
    13. 13. Patient # 74: Baseline • 67 year old female • Baseline NIHSS: 8 despite right MCA M1 segment occlusion. • Good collateral flow and preservation of lenticulo striates • 7 hrs 10 min from onset to arterial puncture 14 1274.C
    14. 14. Patient # 74: Post-Penumbra • 041 Reperfusion Catheter and 041 Separator X2 restored flow to distal vascular bed. • 38 min revasc. time • Discharge NIHSS: 0 • 90 Day NIHSS: 0 • 90 Day mRS: 0 • Excellent recovery despite late time to arterial puncture. 15 1274.C
    15. 15. Patient # 34: Baseline • 70 year old female • History of Afib. • Baseline NIHSS: 14 despite left MCA superior M2 segment occlusion with intact lenticulo striates. • 4 hrs 5 min from onset to arterial puncture 16 1274.C
    16. 16. Patient # 34: Post-Penumbra • 026 Reperfusion Catheter and 026 Separators X3 efficiently opened small, tortuous M2 • 21 min revasc. time • Discharge NIHSS: 0 • 90 Day NIHSS: 0 • 90 Day mRS: 0 17 1274.C
    17. 17. Patient # 37: Baseline • 60 year old male • Baseline NIHSS: 12 despite left ACA A3 occlusion • 5 hrs 20 min from onset to arterial puncture 18 1274.C
    18. 18. Patient # 37: Post-Penumbra • Flow restored • 32 min revasc. time • 026 system reached A3 segment safely • Discharge NIHSS: 1 • 90 Day NIHSS: 1 • 90 Day mRS: 1 • Excellent recovery indicates treatment of A3 occlusion was warranted 19 1274.C
    19. 19. Stenting • Carotid stent • Vertebral orifice stent • Intracranial stent
    20. 20. • • 20% • Onyx 50%
    21. 21. Onyx • Ethylene vinyl alcohol copolymer EVOH • Solvent--DMSO - Dimethyl sulfoxide • • •
    22. 22. Isil Saatci Saruhan Cekirge Ankara, Turkey
    23. 23. • 350 AVM (158 grade 1-2, 192 grade 3-5) • 179 (51%) complete obliteration • Others • 136 referred to RTO • 27 referred to surgery • 4 discontinued therapy • 5 died
    24. 24. • Total cure rate 178/350 (50.6%) • Mortality rate 1.4% (procedure related 1.1%) • Permanent morbidity rate 7.1% • Permanent closure 98.9%
    25. 25. Image study • CT • MR • Angiogram • SPECT • PET • Xenon CT
    26. 26. Image study • Vascular anatomy • 3D reconstruction • Perfusion study • qualitative vs quantitative • Others • phase contrast MR(measure flow rate)
    27. 27. X-ray • Fluoroscope • Roadmap • Subtraction • Rotation
    28. 28. What’s different from surgery • From inside the vessels • blood flowing • blood clotting • every vessel is reachable (sort of)
    29. 29. You need to? • learn • handle X-ray equipments • complete cerebrovascular anatomy • setting up the system • different catheter, wires, stent, coils...
    30. 30. Taiwan • Neuroradiology • Handle X-ray equipment • Have techniques in angiography • Access to all image modality • Pioneer in this field in Taiwan
    31. 31. Taiwan • Neuroradiology • no patient care experience • need neurosurgeons backup • more conservative • low income from treatment
    32. 32. 

    33. 33. Taiwan, French, Australia, Neuroradiologist Brazil, Portugal, Italy Neurosurgeon Japan, Austria Neuroradiologist US, Korea Neurosurgeon Neurosurgeon China Neurologist
    34. 34. Taiwan • Neurosurgeon • We have patients • Know more of these diseases • More aggressive • More treatment choices • Can negotiate the “insurance issue”
    35. 35. We can now • Perform all interventional procedure • Use most catheters, wires, balloons • Use ordinary coils, embolizers • Use any stuffs not cover by
    36. 36. We can not • Apply • Detachable coils ( ) • Carotid stent ( )
    37. 37. Coil • • • • •
    38. 38. Neurosurgery Surgery Endovascular Combined 30 24 22 20 18 17 16 12 13 12 8 6 4 2 0 1995 2000 2005 Number of papers related to treatment of vascular disease
    39. 39. Cerebrovascular Dz 5% Hemorrhagic 25% Ischemic 70% Ischemic Hemorrhagic Others
    40. 40. CCF Surgical treatment Aneurysm Many Years ago Spinal AVM Malignant infarction Carotid stenosis DAVF, EC-IC AVM ICH
    41. 41. Surgical treatment Aneurysm Now Spinal AVM Malignant infarction AVM CCF ICH Aneurysm Spinal AVM Carotid stenosis DAVF AVM Endovascular treatment
    42. 42. Surgical treatment Future Malignant infarct EC-IC ICH CCF, ICH Aneurysm Spinal AVM Carotid stenosis DAVF, AVM And......... Endovascular treatment