A 66-year-old man with a history of ear cancer presents to the clinic with bleeding behind his ear. The bleeding becomes worse during the examination, and the patient ends up coding three times before reaching the angio suite.
What do you do next?
- Ponder images
- Stop the bleeding by sacrificing the carotid artery
- Stop the bleeding with a balloon tamponade
- Place a stent graft
This was one of multiple scenarios offered to attendees of the Cerebrovascular Case Conference during SIR 2022, a session that built on the quarterly SIR Stroke Case Conference. Co-coordinators Martin Radvany, MD, FSIR, and Venu Vadlamudi, MD, FSIR, were joined by Joseph J. Gemmete, MD, FSIR, Manraj K. S. Heran, MD, Jasmeet Singh, MD, and Joanna Kee-Sampson, MD, for an interactive discussion designed to enable attendees to ask questions of experienced stroke practitioners.
Presenters brought a multitude of cases and imagery that demonstrated the scope of neurointerventional disease states and techniques, from the carotid endograft revascularization case that Dr. Vadlamudi brought to the challenging natures of extracranial internal carotid artery (ICA) aneurysms.
Some cases were relatively straightforward, while others were far more complex, like the previously placed stent that Dr. Singh had to reconstruction, or the case Dr. Gemmete presented, featuring a 27-year-old man with multiple dissections and pseudoaneurysms. Dr. Gemmete detailed a multiyear process in which various providers attempted to stem a complex carotid pseudoaneurysm. In the end, the patient received six wall stents and two stent grafts.
“This was a very difficult case to treat,” he said, “but we think this is a win.”
Others focused their presentations on their specific techniques and approaches, such as Dr. Heran, who—though he does not describe himself as a “radialist or a femoralist”—detailed why he often chooses femoral access.
“It’s a faster setup,” he said, “and a lot of equipment still favors the femoral approach.” In addition, he said, it’s often more ideal for room ergonomics and patient movement.
However, there are cases in which femoral access is not a good idea, he said, such as in situations with an occluded or stenotic brachiocephalic or left common carotid artery origin.
Dr. Heran also briefly discussed pediatric interventions, noting that devices are not trialed on patients under 18. “But when you have a pediatric patient, it’s not a matter of not treating the kid. It’s in deciding how to.” Dr. Heran says he prefers groin access in these cases and provided suggestions as to the size of catheters that he will typically use to accommodate pediatric anatomy.
Not all cerebrovascular cases feature complex stroke treatments, however. In her presentation, Dr. Kee-Sampson focused on three epistaxis patients. “Nosebleeds are a fairly common condition, and rarely need medical treatment,” she said. “But in the cases that don’t stop bleeding after initial management, those patients either go to surgery for ligation or endovascular embolization.”
She shared tips for these types of cases, telling attendees that she likes to start with a common carotid or angiogram for imaging. She also advised attendees to make sure that during the procedure, the microcatheter is distal to the middle deep temporal artery, to avoid post-embolism trismus and pain.
Each case was presented as an interactive discussion with attendees—to embolize or not to embolize? Use a balloon, or sacrifice the carotid artery?
For those who answered the question of the 66-year-old man with ear bleeding with “C. Stop the bleeding with a balloon tamponade,” Dr. Radvany agreed.
“First thing you ever do is stop the bleeding,” he said. “Have a balloon ready and buy yourself some time.”
Missed this session? It’s available to watch anytime via SIR Now.
